Download WOUND CARE

CHAPTER
WOUND CARE
(8 CONTACT HOURS)
Learning objectives
!! Compare and contrast the various types of
acute and chronic wounds.
!! Identify the incidence and prevalence of
acute and chronic wounds within the United
States.
!! Describe the normal anatomy and
pathophysiology of the skin.
!! List each of the phases required in order for
the skin to heal normally.
!! Compare and contrast the three ways wounds
close.
!! Identify the generalized factors that affect the
normal healing process.
!! Compare and contrast the different risk
factors for each of the acute and chronic
wounds.
!! Describe the nurse’s responsibility
in completing the wound history and
assessment.
!! Describe treatment modalities for each of the
wounds.
!! Identify the nurse’s responsibility in
preventing acute and chronic wounds from
occurring within the community and hospital.
!! Identify the legal aspects for the nurse caring
for a patient with a chronic wound.
Introduction
Wounds may be acquired from many different
sources, such as bites, burns, punctures, scrapes,
skin tears, surgically provoked and/or chronic
wounds, such as pressure ulcers typically
induced from lack of mobility or leg ulcers that
result from venous or arterial insufficiencies.
Therefore, it may be difficult to assess the wound
based upon the nature of origin, the patient’s
risk factors, and/or other co-morbidities that
may affect the healing process. There are many
wound-care dressings and products that may be
prescribed by providers, and it may be difficult to
understand the reason one product and/or type of
dressing may be utilized over another for what a
nurse may perceive as a similar wound.
Ideally each facility should have a wound-care
nurse to ensure that the proper dressings and/
or products are being utilized appropriately for
various types of wounds. However, realistically,
a wound-care specialist may not be feasible or
easily accessible. Therefore, it is imperative that
nurses are enlightened and knowledgeable about
the various products to ensure that wounds will
be properly treated.
There are many variables that intertwine and
affect the healing process and capabilities.
Therefore, throughout this educational offering
the most common wounds will be analyzed and
described to ensure that nurses and health care
professionals are able to properly identify and
treat the different types of wounds that may
present on any shift assignment. In addition,
it is important for the nurse to understand the
mechanism behind the wound injury to prevent
certain wounds, recognize the potential risk
factors that predispose patients to various wounds
and then to be able to properly identify and treat
the wounds appropriately.
Common skin injuries
The definition of a wound is a breach in the
external surface of the body [82]. Anytime there
is a break in the outer layer of skin, also known
as the epidermis, there is a wound. Depending
upon the nature and degree of the wound, the
overall well-being of the patient may be affected
by the injury and/or complications of the wound.
Therefore, nurses must be able to recognize the
injury, then respond to it quickly to reduce the
risk of complications, especially with wounds
that are contaminated immediately due to the
mechanism of the injury.
The most common wounds will be explored.
Acute wounds include but are not limited to
abrasions, lacerations, puncture wounds, surgical
wounds, burns and skin tears [3]. Chronic
wounds consist of pressure ulcers, venous and
arterial leg ulcers, diabetic foot ulcers and
nonhealing surgical wounds [3].
1. Abrasions, excoriations or scrapes – These
terms are typically used interchangeably
as they are defined by superficial breaks in
the epidermis of the skin due to friction,
force or rubbing against an abrasive surface
and/or a fall [78, 85]. Therefore, if there
is an abrasion, excoriation or scrape, the
deepest layers of the skin remain intact,
such as the dermis and hypodermis. Thus
bleeding is described as a slow oozing
flow, and the skin injury will typically heal
without antimicrobial ointment, unless
there is a foreign body imbedded in it
[78, 85]. According to the Association for
Advancement of Wound Care (AAWC),
the most common sites for abrasions,
excoriations or scrapes occur in [78]:
ŠŠ Upper extremities.
ŠŠ Lower extremities.
ŠŠ Buttocks.
2. Bites – An animal or a human can inflict a
bite, eliciting potential tissue and/or nerve
damage, infection and rabies. A bite may be
considered an abrasion, puncture wound,
laceration, avulsion (the tissue separating
from the body) or a combination of any of
them depending upon the depth of the bite
[85]. Typically, the presentation of the bite is
specific to the particular source, such as:
ŠŠ Dog bites appear as a laceration or
avulsion and typically have components
of a crush injury [31].
ŠŠ Cat bites, in contrast, typically induce
a puncture wound in which bacterial
organisms can be introduced [31].
ŠŠ A human bite is no different than an
animal bite; whether it was accidental
or intentional will typically determine
the severity of damage to the skin. There
are three main types of human bites: a
closed-fist injury, chomping injury to the
finger, and puncture wound clashing with
the head [4]. Each of the examples is
elaborated upon as follows [4]:
Elite CME Closed fist injury occurs from
striking an opponent’s tooth during
a fight.
Chomping injury affects tendons,
and their overlying sheaths are often
affected by the bite.
Head injury may appear as a
mild wound, but deep bacterial
contamination is possible.
All bites are capable of inducing an infection,
but human bites can also potentially transmit
the hepatitis B and human immunodeficiency
virus (HIV) during the bite [82]. In addition,
cat and human bites are more likely to
become infected than dog bites [7].
The unique component of a bite is the vast
array of bacteria species found in the mouth,
and there are usually more than just one
present [51]. For instance, there are more
than 64 species of bacteria found in the
mouth of a dog or cat [51]. However the
most common type of bacteria found in
animal bites is the Pasteurella Multocida
species, found in approximately 75 percent
of cat bites and 50 percent of dog bites [44].
Other types of bacteria that may be found
in animal bites include but are not limited
to staphylococcus aureus, staphylococcus
epidermidis, streptococcus and escherichia
coli (E. coli) [51].
Human bites are typically composed of
streptococcus, staphylococcus, or eikenella
corrodens (found in 30 percent of
all patients) [44]. The reason animal bites
induce infection is attributed to the normal
aerobic flora of human skin coming in contact
with anaerobic and aerobic oral flora of the
biting animal, which is capable of inducing
an infectious process[51].
3. Bruises – Bruising is a visible result or
contusion caused by damaged blood vessels
that are broken during an accident or trauma
[73].
4. Burns – Burns are the leading cause of
accidental death and are typically caused by
the following [20]:
ŠŠ Thermal – Residential fires, automobile
accidents, playing with matches,
improper handling of fireworks, scalds.
ŠŠ Chemical – Contact, ingestion,
inhalation or injection of acids, alkalies,
or vesicants.
ŠŠ Electrical – Contact with faulty electrical
wiring, electrical cords or high voltage
power lines. Teenage boys have a higher
incidence of suffering from an electrical
burn due to their innate demeanor of
being eager to experiment [50].
ŠŠ Friction or abrasion.
ŠŠ Ultraviolet radiation – Sunburn.
ŠŠ Scald – Water or grease.
During a burn injury, collagen is lost, creating
abnormal osmotic and hydrostatic pressure
gradient, which causes the movement of
intravascular fluid into the interstitial space
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[3]. During the cellular injury, mediators of
inflammation are released. One of the most
common forms of burns seen is scalding
due to beverages, food and bath water [3].
According to the American Burn Association,
a scald depends upon the temperature level
one is exposed to and the length of time of
exposure [3]. The American Burn Association
provided the following examples [3]:
ŠŠ The most common standard water
temperature in a home is 120 degrees. If
an individual is exposed to the maximum
temperature for five minutes, he or she
will suffer from a full-thickness injury.
ŠŠ Typically, coffee, hot tea and hot
chocolate are served at 160 degrees;
at 140 degrees, it takes less than five
seconds for one to suffer a burn injury.
5. Lacerations or cuts – Lacerations or cuts
typically go through all layers of the skin into
the fat or deeper tissues, typically induced
by a blow from a blunt object, a fall and/or
contact with a sharp object. Most lacerations
induce bleeding that is brisk or more severe
due to various layers of tissues being torn
[30]. A laceration (cut) may be defined as an
incision or jagged [50].
It is important to note that how the laceration
or abrasion was inflicted will determine how
it will affect the normal healing process and
the risk of infection to the injured area. The
most common bacterial pathogens that affect
lacerations or abrasions are staphylococcus
aureus and B-hemolytic streptococcus [82].
6. Perineal skin breakdown – Research has
demonstrated that incontinence, perineal
skin breakdown and pressure ulcers typically
coincide together [66]. The perineal skin
breakdown occurs because of the moisture
from incontinence, which alters the skin’s
normal protective pH, thus increasing the
permeability of the stratum corneum (the
outermost layer of the dermis) [66]. Perineal
skin breakdown may be exacerbated by feces,
which contains bacteria that will permeate
the stratum corneum, allowing secondary
infections to occur [66].
7. Pressure ulcers are used interchangeably
with decubitus ulcers and/or bedsores in the
majority of the literature. The Agency for
Healthcare Research and Quality (AHRQ)
has endorsed the term pressure ulcers into
its literature and research [41]. Since 2007,
however, the Joint Commission (JCAHO) has
provided definitions differentiating the terms
decubitus ulcers and pressure ulcers [44]:
ŠŠ Decubitus ulcers refer to the breakdown
of the skin and subcutaneous tissue due
to prolonged, unrelieved pressure over a
bony prominence, often associated with
malnutrition, paralysis, and/or physical
deformity. The word “decubitus” means
recumbent or horizontal posture.
ŠŠ Pressure ulcer is a broader term that
includes decubitus ulcers, but also
includes ulcerations associated with
prosthetic limbs or dental prosthesis.
The ulcers that develop from dental
prosthesis typically occur in the elderly.
Unfortunately it can impact their
nutritional status.
ŠŠ The National Pressure Ulcer Advisory
Panel (NPUAP) defines a pressure ulcer
as a localized injury to the skin and/or
underlying tissue, usually over a bony
prominence, as a result of pressure, or
pressure in combination with shear and/
or friction. A number of contributing or
confounding factors are also associated
with pressure ulcers; the significance of
these factors is yet to be elucidated [94].
Pressure ulcers are caused by an impaired
blood supply and tissue nutrition resulting
from prolonged pressure over bony or
cartilaginous prominences [57]. Pressure
ulcers typically occur in localized areas
that involve necrosis at the cellular level
in the skin and subcutaneous tissue over
the bony prominences [53]. Research has
demonstrated that part of the injury related to
pressure ulcers is caused by ischemia to the
area followed by reperfusion (restoration of
the blood flow) [39]. Once the oxygenation
process has been activated, reactive oxygen
species (ROS) causes an uncontrolled
oxidation of vital cellular components, such
as hydroxyl radical (HO) [39]. Therefore,
ischemia-reperfusion (I-R) injury and
reactive oxygen species (ROS) play an
integral role in the pathogenesis of pressure
ulcer development [39].
8. Punctures – Puncture wounds are inflicted
by sharp objects entering the skin, such as
stepping on a nail, getting stuck with a needle
or being stabbed with a knife. Depending
upon the depth and object utilized, the
bleeding may be minimal, and the wound
may not be very noticeable [30].
9. Skin tears – Defined as a traumatic wound
resulting from separation of the epidermis
from the dermis layer of the skin that occurs
with friction or shearing [4]. The majority of
skin tears, approximately 80 percent, occur
on the upper extremities, especially the arms
and hands [9].
10. Surgical wounds – A surgical wound is
defined as a deliberate incision produced
during a surgical procedure; it is the original
incision [26].
11. Ulcers – An ulcer is a concave lesion with
a sunken appearance that is the result of
trauma and/or poor circulation. Ulcers extend
from the epidermis into the dermis layer of
the skin [18]. The most common chronic
wound ulcers are pressure ulcers, diabetic
foot ulcers and leg ulcers. However, due to
the prevalence and wealth of information
revolving around pressure ulcers, it will be
addressed individually here.
ŠŠ Diabetic foot ulcers – Diabetic foot
ulcers typically occur from consequences
of diabetic neuropathy and can cause
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substantial morbidity [38]. The most
common lesion found on a diabetic foot
ulcer is an infected “malperforans” [38].
ŠŠ Leg ulcers – The most common cause of
leg ulcers is venous or arterial (ischemia).
Differentiating between the two types
of ulcers can be very challenging for
practitioners; therefore it is imperative
to properly assess the wound. Arterial
ulcerations and mixed arteriovenous
ulcers (a combination of venous and
arterial disease) comprise 14 percent of
all leg ulcers; 75 percent are related to
venous ulcers [47].
ŠŠ Arterial/ischemia – Arterial ulcers
are the result of peripheral vascular
disease due to atherosclerosis with micro
vascular or macro vascular changes [47].
ŠŠ Venous – The main culprit of venous
ulcers is related to venous hypertension
[25]. Chronic venous insufficiency is
caused by high pressure in the veins that
occurs due to abnormal blood flow [61].
Anatomy and pathophysiology of the skin
In order to understand the various types of
wounds that may occur, it is imperative to
recognize the duty and purpose of each layer
of skin because the affected portion during the
wound injury may determine the effect on the
healing process. The skin is the largest organ of
the body and the primary mode of defense for the
body. If there is a break or injury to the skin, it
will affect homeostasis and can affect the overall
health of the patient [41]. The total surface of
the skin ranges from 15 to 20 square feet and
accounts for 15 percent of the total body weight
[72]. The majority of literature concludes that
skin has four major functions [19, 28]:
Acts as a barrier for protection of underlying
structures against microorganisms and
infectious agents.
Protects and regulates the body temperature
through conduction, convection and radiation.
Aids in elimination of waste.
Prevents dehydration.
However, the skin has many additional functions
in order to keep the body protected and
functioning at an optimal level [41, 74]:
Resistance to trauma and infection.
ŠŠ The epidermis protects the body and skin
from injury through [41]:
Keratin, which provides protection to
the epidermis layer.
The epidermis, which inhibits
proliferation of microorganisms
because of its dry external surface.
The epidermis, which protects the
skin through intracellular bonds.
ŠŠ The dermis protects the skin through
the fibroblasts, which facilitate wound
healing processes. In addition, the dermis
provides mechanical strength through
collagen, fibers, elastic fibers and ground
substances such as fibroblasts.
ŠŠ Vitamins – The epidermis produces and
regulates vitamin D synthesis.
ŠŠ Sensation – The dermis layer transmits
Elite CME
Stratum basale consists of a single
layer of low columnar stem cells
and keratinocytes on the basement
membrane.
Stratum spinosum consists of
several layers of keratinocytes.
Stratum granulosum consists
of three to five layers of flat
keratinocytes, typically in the thicker
skin.
Stratum lucidum consists of a thin
translucent zone superficial to the
stratum granulosum, typically seen
only in the thick skin.
Stratum corneum is the outermost
layer of the dermis. It contains over
30 layers of dead, scaly, keratinized
cells that make it waterproof.
Keratinocytes are dead squamous
Although some texts disagree on the number of
cells that form the protective barrier
layers found in the skin, here we will explore
of the skin. The average life of a
each of the major layers because a wound injury
keratinocyte is about 28 to 45 days in
may affect one or multiple layers of the skin. The
which it will shed (exfoliate) [41]. If
majority of textbooks concur that the two major
the stratum corneum is not intact, the
layers of the skin are the epidermis (a stratified
normal skin bacterium invades deeper
squamous epithelium) and the dermis (a deeper
into the skin, eventually accessing the
layer of connective tissue) [72]. The other two
bloodstream [19].
layers are important to mention because a breach
ŠŠ The epidermis is composed of five to six
in any aspect may affect the overall well-being of
types of cells [72]:
the patient:
Stem cells are found in the deepest
1. Subcutaneous fat (adipose tissue) – There
layer of the epidermis, called stratum
is another layer of the skin that lies over the
basale.
muscle and bones, the subcutaneous fat, also
Keratinocytes are the most abundant
known as adipose tissue [41].
of the epidermal cells.
2. Hypodermis – Beneath the dermis, there is
Melanocytes occur only in the
another layer of connective tissue, composed
stratum basale.
of subcutaneous tissue or superficial fascia
Tactile (merkel) cells are relatively
that connects the overlying dermis to the
small in amount but are the receptors
underlying muscle [53]. The hypodermis
for the sense of touch.
(subcutis) is not typically alluded to as being
Dendritic (Langerhan) cells are
part of the skin but is typically correlated in
found in two layers of the epidermis,
studies with the main two layers of the skin,
called the stratum spinosum and
the epidermis and dermis layers [72].
stratum granulosum. The dendritic
The skin is composed of two major layers [53,
cells are macrophages that originate
72]:
in the bone marrow, but migrate to
Epidermis – The epidermis is the most
the epidermis and other epithelial
important layer of the skin because it is on
cells. The unique component of
the outside, exposed to all of the external
the dendritic cells is that they are
variables. The epidermis is composed of
the invaders during any injury or
keratinized stratified squamous epithelium,
infection and they alert the immune
which consists of dead cells packed with a
system to fight off the pathogens that
tough protein keratin. The epidermis has a
penetrate into the skin.
limited supply of blood to provide nutrients
Dermis – The dermis is a deeper layer,
and thus depends upon the diffusion of
located above the adipose tissue (fat pad)
nutrients from the underlying connective
[41]. The dermis is composed of irregular
tissue, the dermis.
connective tissue with a rich blood, lymphatic
ŠŠ The majority of the epidermis skin is very
and nerve supply; however it does not have
thick, approximately 1 to 2 millimeters
any cells [41]. Therefore the dermis is rich
(mm) in size; however the thickness
in sensory nerves, which allows a patient to
varies depending upon the location, such
feel touch, pressure, temperature, pain and
as:
the urge to scratch/itch (pruritis) [41]. The
Eyelids, less than 0.5 mm.
dermis is composed mainly of collagen, but
Shoulders, up to 6 mm.
it has reticular fibers, fibroblasts and other
It will thicken as needed from corns or
fibrous connective tissue that allows it to
calluses in areas of constant pressure or
be flexible [41]. Anytime there is an injury,
friction.
collagen production increases as it forms scar
ŠŠ The epidermis is composed of four to five
tissue [41]. The dermis size varies from 1 to 4
layers of cells [72]:
mm in thickness [72] and is composed of two
sensations through the neuroreceptor
system, enclosing an extensive network
of nerve endings for relaying sensations
to the brain.
ŠŠ Thermoregulation – The epidermis
layer regulates the temperature through
eccrine sweat glands as they dissipate
heat through the evaporation of sweat
secreted onto the skin surface. The
dermis layer regulates the temperature
through cutaneous vasculature dilation or
constriction from the skin surface.
ŠŠ Homeostasis – The epidermis is able
to regulate homeostasis through low
permeability to water and electrolytes; in
the dermis, the lymphatic and vasculature
tissues respond to inflammation, injury,
and infection.
Elite CME layers, the papillary and reticular layer [72]:
ŠŠ Papillary layer is a thin zone of areolar
tissue in and near the dermal papillae.
ŠŠ Reticular layer of the dermis is deeper
and much thicker. It consists of dense
irregular connective tissue.
Normal wound healing
Ideally, the goal for all patients who present
with a wound is for optimal healing at the
cellular level. However, there are circumstances
in which that doesn’t happen. The depth of a
wound determines whether the wound is at
risk of becoming infected with bacteria, other
substances, or whether it will leave a scar
[28]. Wounds that do not penetrate the stratum
germinativum, the basement layer of the skin, do
not leave scars [28]. In order for wound healing
to occur, two processes need to occur [86]:
Regeneration to repair lost tissue with
identical functional tissue.
Connective tissue repair is lost tissue being
replaced by formation of a scar.
Once the skin has been broken, there are a few
phases that need to occur simultaneously to
ensure that wound healing occurs efficiently and
the area reaches its optimal level of functioning
[28]:
Injury phase – Once the injury occurs,
the physiological aspects of the body are
immediately working to restore a functional
barrier to prevent further injury and/or
damage to the skin. The injury phase is when
the injury initially occurs, and involves the
initiation and release of coagulating factors
to halt the bleeding process by narrowing
the blood vessels, thus forming a clot. In
addition, platelets are initiated and released
to facilitate the healing process. The
explanation of platelets will be discussed
in the inflammatory phase as they work
simultaneously, typically overlapping phases.
Epithelialization – During this phase, the
epithelial cells (keratinocytes) migrate across
the wound surface providing new skin to act
as a protective barrier and to protect against
excessive water loss and bacteria [30]:
ŠŠ The epithelialization phase typically
begins its reconstructing within a few
hours after the injury and it is complete
within 24 to 48 hours in a clean, sutured
wound.
ŠŠ If it is an open wound, it may take seven
to 10 days because the inflammatory
process is prolonged, thus increasing the
risk of the wound scarring. However,
it may be delayed in dehydrated,
deoxygenated skin [41].
Inflammatory phase – The inflammatory
phase is initiated immediately after any
injury, thus occurring simultaneously with
the injury phase. The inflammatory phase
typically lasts two to five days [78]. During
this phase, the damaged tissue will release
chemical mediators, such as cytokines,
which are responsible for initiating complex
processes that cause homeostasis and
begins the healing process [28]. During
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this inflammatory phase, there are other
chemicals that are released to promote the
healing process and clear the wound of debris
[28]:
ŠŠ Vasoconstriction occurs to reduce
bleeding at the site of injury.
ŠŠ Platelets aggregate, inducing bleeding,
which is contradictory to it also releasing
vasoconstriction methods, but with the
combination of serotonin it activates the
coagulation cascade. This process results
in the conversion of fibrinogen into fibrin,
which forms a platelet plug.
The platelet plug activates
vasodilatation and increases capillary
permeability, which allows plasma
to leak into the tissue surrounding
the wounded area also known as the
inflammatoryexudate.
ŠŠ Thromboplastin – Makes a clot. Once
the homeostasis component is complete,
monocytes and neutrophils are released
to the site of injury. The monocytes
activate the macrophages, which produce
growth factors and cytokines. The
monocytes are the immature white blood
cells; the macrophages are the mature
white blood cells. The macrophages are
responsible for wound debridement [81].
The neutrophils trap and kill bacteria
immediately. Once the wound becomes
mononuclear, the neutrophils and
macrophages will cease, signaling the
end of the inflammatory phase and the
initiation of the proliferative phase [18].
During the inflammatory process, the skin
will exhibit the following appearance [81]:
ŠŠ Redness due to the vasodilatation process
per prostaglandins being released, such as
prostacyclin (PG12).
ŠŠ Edema due to the leakage of plasma
proteins through gaps in the vascular
endothelium. Edema is caused by
prostaglandins, which also promote blood
flow, contributing to the heat and edema
around the wound. Once the wound is
inflamed and warm to touch, it allows
inflammatory cells to enter the wound
due to increased vascular permeability.
ŠŠ Heat as explained under edema.
ŠŠ Pain is elicited by the effects of PG12
and other prosta-glandins as they exert
their effects on the sensory nerve endings.
Proliferative phase – The proliferative phase
typically begins to work within two to three
days after the injury; it is stimulated by the
arrival of fibroblasts into the wound [81]. The
proliferative phase is known as a matrix or
latticework of formation of cells [30]. The
proliferative phase is broken down into three
stages [92]:
ŠŠ Granulation – During the granulation
phase, new skin cells and blood vessels
form to nourish the area as they supply
and rebuild the cells with oxygen and
nutrients to support the production
of proteins, also known as collagen
[30]. Collagen is the major component
of acute wound healing, which takes
approximately six weeks [81]. The
major reason that collagen fibers work
efficiently is that macrophages recruit
fibroblasts [28]. The fibroblasts are driven
by the macrophage that proliferate and
synthesizes glycosaminoglycans and
proteoglycans, the building blocks of the
new extracellular matrix of granulated
tissue and collagen [81].
ŠŠ Contraction consists of wound edges
pulling together to reduce a defect in the
wound healing process and potential scar
formation [92].
ŠŠ Epithelialization crosses moist surfaces,
and cells travel about three centimeters
(cm) from the point of origin in all
directions [92].
During the inflammatory process, the skin
will exhibit the following appearance [30]:
ŠŠ The new small blood vessels, or
capillaries, provide a pink and/or purple
erythemic appearance. The proliferative
phase typically lasts two days to three
weeks [28].
Remodeling phase – The remodeling phase
is the final process. It typically begins two
to three weeks after the injury to the skin.
During this time, the collagen is more
organized, ensuring that the tissue is stronger.
Typically the blood vessels become less
dense as demonstrated by the wound losing
the pinkish appearance [30].
The appearance of the wound changes
throughout this period, which is a reason
many plastic surgeons wait six months before
revising a scar [28]. In addition, the scar
tissue is approximately 80 percent as strong
as the original tissue [92]. Thus, if there is
repeated injury and/or trauma to the area, scar
tissue forms making the area harder and more
difficult to treat if surgery is required.
Methods of wound closure
Another factor that contributes to the healing
process is the type of method used to close the
wound. The provider will choose the optimal
manner to close the wound, dependent upon the
patient’s history, the amount of tissue damaged
or lost during the injury and the potential for
infection [86]. The primary methods of wound
closure include primary, secondary and tertiary
intentions [50, 86]:
First intention healing involves the primary
closure of the wound by mechanical
mechanisms, such as tape, sutures, staples or
glue. Steri-strips should be utilized if it is not
over a hairy surface or joint.
ŠŠ The method of first intention is preferred
if there is minimal tissue loss and the skin
edges are well approximated. The wound
will repair through the normal phases
of wound healing process. If the patient
has no risk factors and/or co-morbidities,
the incision line is resurfaced and able to
fight potential bacteria within 72 hours
Page 4
of closure. Although the external surface
may appear as if it is healing adequately,
the nurse and patient should not assume
the integrity of the skin is functioning at
the optimal level as it takes more time to
heal.
ŠŠ A healing ridge occurs along the incision
line between days five and nine days after
repair. The healing ridge is exhibited by
firm edema or induration and it extends
approximately 1 to 2 centimeters (cm)
outside the incision line. It is important
to assess for this ridge, as failure to
notice may imply further treatment or
intervention is needed to relieve stress on
the wound. Therefore, the nurse should
contact the doctor. The proliferative
phase may take up to 21 days to heal. The
advantage of first intention healing is that
there is typically limited scar formation
once the wound has healed.
Examples of primary intention
closure include surgical incisions.
Secondary intention healing involves
wounds that are left open to heal
spontaneously or surgically due to significant
tissue loss, damage and/or bacterial
contamination. The healing process is
typically extended due to the multiple layers
of skin damage. Granulation occurs, and
will induce bleeding in the wound. Deep and
wide scars eventually form once the wound
is healed.
ŠŠ Examples of secondary intention include
open abdominal wounds, dehisced
wounds, stage three or four pressure
ulcers, burn injuries, traumatic injuries
and infected wounds.
Tertiary intention healing involves a
combination of primary and secondary
intention. Typically the physician will leave
the wound open for a short period of time to
allow the edema and exudate to resolve and/
or diminish. During this time, the nurse will
be responsible for packing the wound with
normal saline and dressings. Once this short
period is over, the physician will close the
wound by primary intention. The primary
goal of treatment with tertiary intention is
promoting the restoration of the skin and
tissue integrity to the physiological optimal
levels. In order for the wound to heal,
multiple facets are considered.
Factors that affect the healing process
There are certain co-morbidities, lifestyles and/
or medications that patients may be taking
that can affect the ability of their skin to heal
appropriately. The most common factors that
contribute to the inability of the wound to heal
properly are [78,81]:
1. Age – Aging of the body affects the
structure and function of the skin. During
the aging process, everything slows down,
including the phases of wound healing
[86]. Functional changes in the skin include
a decreased inflammatory response and
Elite CME
thinning of the skin, which predisposes
the elderly patient to fragility and injuries
[19]. There are a few physical findings in
the elderly that affect their ability to heal
appropriately within the layers of the skin
[41, 71]:
ŠŠ Epidermis.
Decreased thickness in the epidermal
layer that causes an increased
transparency and fragility.
Delayed wound healing due to
decrease in cell replacements.
Decreased number of Langerhans
cells.
Change in the size and shape of the
keratinocytes.
ŠŠ Dermis.
Decreased dermal blood flow, which
causes an increased susceptibility to
dry skin (xerosis).
Decreased dermal thickness, which
causes a paper-thin, transparent
appearance increasing the risk of
pressure ulcers.
2. Nutrition – It is imperative that the patient
has optimal nutritional intake to promote
healing. If the patient lacks the necessary
nutrients, the wound is unable to maintain
adequate energy for collagen synthesis and is
unable to heal appropriately [87].
3. Obesity – A patient who weighs greater than
20 percent of his or her ideal body weight
is at greater risk of dehiscence, herniation
and infection, thus exacerbating the wound
healing process [86]. Obese patients have an
abundant amount of adipose tissue, which is
poorly vascular, thus increasing the incidence
of ischemia. The nurse can reduce the risk of
complications of dehiscence and herniation
by encouraging the patient to utilize a binder
or splint over the incision during straining or
coughing [86].
4. Presence of debris, necrotic tissue and
infection – Infection can cause collagen
lysis. Tissue necrosis occurs from radiation
treatments, which may increase the risk of
local or systemic ischemia.
5. Repeated trauma – If a patient has multiple
wounds or surgeries, then the body’s
immediate defense mechanisms become
limited due to the multiple requirements of
the body at the same time.
6. Skin and moisture – Skin must have an
adequate amount of fluid to ensure adequate
functioning and viability of the tissue.
Each of the layers of skin typically holds a
certain amount of water [60]:
ŠŠ Dermis contains about 80 percent.
ŠŠ Stratum corneum about 30 percent, which
is not uniformly distributed, varying
from approximately 40 percent in the
inner layers to 10 to 15 percent in the
outermost layer. However, it can increase
to approximately 60 percent when the
skin is immersed or exposed to a very
wet environment.
If the moisture in the skin is altered in any
format, even at a minimum level of 10
percent, the patient may exhibit dryness
and scaling of the skin, thus predisposing
the patient to further skin breakdown and
potential infection [80]. In severe cases,
total dehydration induced by death of the
underlying dermal structures will lead to the
formation of eschar, commonly associated
with pressure ulcers [80].
According to World Wide Wounds (WWW)
(2008), the effect of moisture on the skin can
be described by a simple phenomenon that
every individual can relate to on a daily basis
[80]:
ŠŠ After an individual takes a shower
or bath, the skin will appear soft and
wrinkled, which occurs from water
permeating the intracellular spaces,
crossing over the cell membranes then
swelling the corneocytes. The same
concept and phenomena is applicable if
the integrity of the epidermis is seriously
compromised by trauma, metabolic or
physiologic disorders. The healing rate
of the wound will be influenced by the
moisture content of the surrounding skin
and the local environment.
If the skin is too dry, epithelialization
will be delayed.
If the skin is too wet, the patient is at
risk for developing maceration and/or
infections.
7. Systemic causes – Common systemic
disorders include diabetes mellitus (DM),
malnourishment and immunodeficiency. DM
plays an enormous role in the healing process
of wounds and potentially predisposes
the patient to wounds due to diminished
sensation and poor arterial flow. The
patient with DM is compromised due to
the microvascular/macrovascular changes,
poor glycemic control and loss of sensation
(peripheral neuropathy). It is imperative to
gain adequate control of the blood glucose
in the diabetic patient to promote wound
healing.
ŠŠ Due to various systemic health
conditions, the patient may be prescribed
various drugs that may further exacerbate
the healing ability of the skin. There are
certain drugs that patients may take for
other disease processes that may induce
thinning of the skin, such as long-term
steroids. Other diseases that may affect
ability to heal include autoimmune
disorders such as rheumatoid arthritis
(RA) and systemic lupus (SLE).
Typically, RA and SLE impair the healing
process, and they require systemic
steroids or immunosuppressive agents,
which further exacerbate the wound’s
ability to heal [87].
8. Tissue hypoxia – The most common
causes of tissue hypoxia are related to
arterial occlusions or vasoconstrictions,
hypotension, hypothermia and peripheral
Elite CME venous congestion. If there is a limited
supply of oxygen to the wound, it inhibits the
production of collagen. When the patient has
an inadequate amount of oxygen circulating
throughout the bloodstream, the patient
will endure vasoconstriction. This may be
the result of low blood volume, unrelieved
pain or hypothermia. Any time a wound has
excessive tension on the edges, it induces
local tissue ischemia and necrosis of the area,
thus impeding normal wound healing.
ŠŠ Smoking also leads to tissue hypoxia.
9. Xerosis (dry skin) – Individuals who endure
dry skin, especially the elderly, are at risk
for skin lesions, excoriations, infection and
lichenification (thickening) due to scratching
and rubbing the skin and thus further
exacerbating the difficulty for the skin to heal
adequately [41].
10. Wound infection – All wounds are
contaminated with bacteria due to the
injury process. However, the host’s immune
competence and the size of the bacterial
inoculum determine whether the wound will
become infected. If the patient has normal
host defenses and adequate debridement, then
a wound may have 100,000 microorganisms
per gram of tissue and still heal effectively. It
is important that nurses recognize that due to
the lack of inflammatory response that occurs
in the elderly, the geriatric population may
not exhibit the typical signs and symptoms
of infection such as fever, erythema and
swelling at the site. However, in the elderly,
the patient may have increasing pain, fatigue,
anorexia and/or changes in the mental status
[50].
Risk factors for developing various
wounds
Typical wounds that nurses care for in the
hospital, out-patient and/or home health settings
are usually secondary lesions that are acute or
chronic. However, collecting a thorough history
and analyzing risk factors to assess the patient’s
co-morbidities will enable one to differentiate
between acute and chronic wounds. The time
frame of the wound being inflicted and the
patient’s risk factors and co-morbidities will help
the nurse identify the anticipated healing process
and make the differentiation. [98]:
Acute wounds heal promptly, within three
to 11 days with an adequate immune system
and no other co-morbidities. Otherwise, an
acute wound may heal in 30 days. However, a
nurse can expect an acute wound in a diabetic
to heal within 60 days.
Chronic wounds take longer than 30 days
if the patient is not diabetic. If the patient
is diabetic, the healing process is affected
tremendously because of the disease process
of the DM and problems regulating blood
sugars and further complications that
develop, especially chronic wounds.
1.
Abrasions, excoriations or scrapes –
Minor risky behavior can predispose an
individual to a minor skin injury, such as:
Page 5
ŠŠ Bicycling.
ŠŠ Playing ball.
ŠŠ Skateboarding.
In addition, abrasions may occur on a
patient who is elderly, frail or confined to a
wheelchair [4].
2. Bites – Children are more likely to be bitten,
but individuals over 50 and those who are
immunocompromised are more likely to
develop an infection [6, 27].
3. Bruising – Anything can cause a bruise
on the skin, but patients at the highest
risk include the elderly and individuals
at risk of falling. In addition, depending
on the location of the bruising or whether
a hematoma is present, the nurse should
assess for a family history of any clotting
disorders, hemophilia or whether the patient
is taking any anticoagulants or nonsteroidal
anti-inflammatories (NSAIDS) that may
exacerbate the problem or inflict bruises on
the skin [4 ].
4. Burns – Everyone is at risk from suffering
from a burn, but those with the highest
risk factors are children, the elderly and
individuals who have disabilities [3].
Research has determined that the following
may affect the patient’s mortality risk [57]:
ŠŠ History of electrical injury.
ŠŠ History of concomitant trauma
(especially penetrating).
ŠŠ Female sex.
ŠŠ Duration of stay in an intensive care unit
(ICU).
ŠŠ Presence of mechanical ventilation.
5. Lacerations or cuts – Patients who use any
tools or sharp instruments in their profession
or as a hobby have higher risks [4].
6. Perineal skin breakdown – The risk
factors for perineal skin breakdown include
incontinence of urine and/or feces.
7. Pressure ulcers – Many of the numerous
risk factors are integrated, thus further
exacerbating the risk of a pressure ulcer
developing, especially for the elderly.
ŠŠ Elderly – The major risk factor is age; 60
to 90 percent of all pressure ulcers occur
in the elderly [19] because of normal
physiological changes that occur in the
aging process, such as [41]:
Cognitive changes – A patient with
a memory deficit may not recognize
the urge to shift or change position
frequently and recognize or verbalize
an area of erythema or pain in his or
her skin.
Skin changes – The skin goes
through a vast array of changes
during the aging process. A few of the
specific contributing factors are:
ŠŠ Thinner skin (atrophy) due
to the dermis decreasing in
size. Once the dermis begins
to decrease in size, the skin
becomes paper-thin and
ŠŠ
ŠŠ
ŠŠ
ŠŠ
translucent in appearance.
Atrophy is the shrinkage of tissue
through a loss in the cell size or
number [72].
ŠŠ Dryer skin due to decreased
vasculature.
ŠŠ Wrinkled skin due to the loss of
elastin fibers.
ŠŠ Loss of muscle.
Immobility – Any patient who requires
assistance in turning or positioning and
who cannot cognitively verbalize the urge
to shift their position is at high risk for an
ulcer formation.
Incontinence – Patients who are
incontinent of their bowel or bladder
functions are exposed to various
chemicals that break the skin down, such
as urea, bacteria, yeast and enzymes [41].
Research has demonstrated that 56.7
percent of patients with pressure ulcers
had fecal incontinence and were 22 times
more likely to have pressure ulcers than
patients without fecal incontinence [66].
Nutritional deficits – Poor nutrition and/
or deficiencies play an important role in a
patient developing pressure ulcers. Intact
skin and wound healing are dependent
upon positive nitrogen balance and
adequate serum protein levels [41].
Disease processes – There are certain
disease processes that may also
predispose an individual to developing
pressure ulcers, such as [53, 78]:
Hip fractures contribute to 66 percent
of elderly adults with a pressure ulcer
[19].
Neurological disorders due to loss
of sensation, rather than being
immobile, such as spinal cord injuries
(SCI), dementia and cerebrovascular
disease (CVA).
Chronic diseases of the
cardiopulmonary system, such as
chronic obstructive pulmonary
disease (COPD), congestive heart
failure (CHF).
Chronic diseases of the endocrine
system, which include DM and
hypothyroidism. It is estimated
that as many as 10 to 15 percent
of the 20 million individuals
living with diabetes are at risk of
developing diabetic ulcers [48].
Patients with diabetes may develop
lower extremity ulcers as a result
of neuropathy with or without
contributing factors [48].
Chronic diseases of the
gastrointestinal system (GI), which
include malnutrition, vitamin
deficiencies and obesity.
Chronic diseases of the hematological
system, such as anemia,
polycythemia and myeloproliferative
disorders. With sickle cell anemia, a
patient may develop lower extremity
ulcers that may resemble venous
Page 6
ulcers or other injuries to the lower
extremities [48].
Chronic diseases of peripheral
vascular pathology, such as
atherosclerotic disease, chronic
venous insufficiency and
lymphedema.
Chronic diseases of the renal system,
such as renal failure or incontinence.
Other chronic disease processes, such
as edema and sepsis.
8. Punctures – Emedicine health has identified
that most puncture wounds are caused
by risky behavior or an occupation that
predisposes an individual to sharp items. The
most common causes of puncture wounds are
wood splinters, pins, nails, glass, scissors and
knives [29].
9. Skin tears – The major risk factor for skin
tears is fragile skin in the elderly population
[4]. In addition to the elderly, other
individuals at risk for a skin tear include [4]:
ŠŠ Individuals who are dependent upon
caregivers for maintaining their activities
of daily living (ADL).
ŠŠ Individuals who use wheelchairs.
ŠŠ Individuals with visual, mental or sensory
impairments.
10. Surgical wounds – Although there is a risk
of infection with any surgical procedure,
the Study of the Efficacy of Nosocomial
Infection Control (SENIC) has identified four
major risk factors for a patient developing a
postoperative wound infection [46]:
ŠŠ Abdominal surgery.
ŠŠ Surgery lasting more than two hours.
ŠŠ Contaminated or dirty wound
classification (See Treatment of surgical
wound).
ŠŠ Patient with at least three medical
diagnoses.
The SENIC has suggested that patients with
two or more of the four risk factors are at an
increased risk of developing a postoperative
surgical wound infection, and they should
definitely receive prophylactic antimicrobial
treatment [46].
11. Ulcers
ŠŠ Diabetic foot ulcers – The major risk
factors include diabetes and a diagnosis
of it more than 10 years ago, having poor
glucose control or having cardiovascular,
renal or retinal complications or being a
male. [19].
ŠŠ Leg ulcers:
Arterial ulcers – While peripheral
vascular disease (PVD) is a major
cause of developing arterial ulcers,
patients with diabetes mellitus,
trauma or advanced age also are at
risk [76].
Venous ulcers – Venous ulcers
are present in just 3.5 percent of
all patients over 65 years of age.
However their recurrence rate is more
than 70 percent [19]. Patients are
Elite CME
at risk of developing venous ulcers
if they have a history of deep vein
thrombophlebitis and thrombosis,
a failed calf pump, advanced age,
pregnancy and/or a family history
of venous ulcers [76]. Another risk
factor is immobility of the calf
muscle, such as a paraplegic might
have [56].
Wound history and assessment
It is imperative to correctly identify any potential
skin injuries to prevent complications. Once a
wound or break in the skin has been noted, nurses
and practitioners need to properly assess the
patient by gathering a complete history of present
illness, current/past medical history, medications
and a social history because each of these
variables may affect the healing process. Once
the history has been obtained, it is imperative to
assess the patient completely, not just the wound.
There are numerous organizations and guidelines
to help reduce the incidence and prevalence
of pressure ulcers nationwide. One of the
organizations, the Institute for Healthcare
Improvement (IHI), initiated and developed the 5
Million Lives campaign that sought a reduction
of 5 million instances of harm from December
2006 through December 2008. To help do so,
the IHI created stringent guidelines to reduce
the incidence and prevalence of various disease
processes, such as pressure ulcers, from occurring
in health care facilities.
Skin risk assessment tool
Every patient admitted to a facility is required
to have a skin risk assessment tool (such as
the Braden scale) completed and a complete
wound assessment upon admission according
to the guidelines of JCAHO and the majority of
hospitals.
Nurses complete an initial skin assessment
to reduce the risk of pressure ulcers or any
skin breakdown from developing during the
hospitalization. Depending upon the facility’s
policies and protocols, nurses may be required to
complete the skin assessment more frequently on
their patients. According to the guidelines of the
Gerontological Nursing Interventions Research
Center and summarized in the National Guideline
Clearinghouse, facilities should abide by the
following reassessment guidelines [16]:
Acute-care patients should be assessed on
admission, then reassessed at least every 48
hours. However, patients with risk factors or
co-morbidities admitted in high-risk areas
such as the intensive care unit (ICU) should
be reassessed one to two times a day.
Long-term care patients should be assessed
on admission and then reassessed every 48
hours for the first week, then weekly for the
first month, then quarterly or whenever their
health status changes.
Home health care patients should be assessed
on admission, then reassessed at every visit.
If the facility where a nurse is employed
recommends more frequent skin assessment risk
tools or reassessments to be completed, the nurse
needs to adhere to the employer’s protocol.
The AHRQ (formerly Agency for Health
Care Policy and Research) is an organization
that works on providing clinical practice
guidelines on pressure ulcer prevention. The
AHRQ recommends an initial pressure ulcer
risk assessment upon admission to a facility
and then periodic reassessments [43]. The IHI
recommends daily assessments on all patients
at high risk or once their condition has changed
[43]. In addition, if the patient is identified as
high risk based upon the assessment, the patient
should be properly identified with a visual cue,
which could be placed on the patient’s chart, arm
band and in the patient’s room to ensure all staff
members are aware that the patient is at high-risk
for developing a pressure ulcer [43].
Since February 2006, JCAHO has recommended
in its national patient safety goals that all health
care providers utilize one of the validated
risk assessment tools, such as the Braden or
Norton scales, to identify all patients at risk for
developing a pressure ulcer, particularly longterm-care patients [44, 92]. Although the Braden
and Norton scales are the most commonly used,
there are other scales that may be used across
the nation, such as the Gosnell, Knoll and/or
Waterlow scales. However, the Braden Scale
developed in 1984 is the most widely used for
predicting the development of pressure ulcers and
any skin breakdown during the hospitalization
admission. The Braden Scale measures skin areas
for [7]:
Sensory perception (the patient’s ability
to respond to meaningful pressure-related
discomforts).
Skin moisture (the degree to which the skin
is exposed to moisture).
Activity (the patient’s degree of physical
activity).
Mobility (the patient’s ability to change and
control body position).
Nutrition (food intake).
Friction/shear.
During the assessment of the Braden Scale, the
nurse is required to rate each of the six categories
objectively, then to document the risk with
a number, one (highly impaired) to four (no
impairment), based upon the patient’s ability to
demonstrate each of the listed categories. Each
of the six categories is assigned a number based
upon the description that best describes the
patient. A patient’s risk is based upon the total
number of points [7]:
Scores of 15 to 18 indicate the patient is “at
risk.”
Scores of 13 to 14 indicate the patient is “at
moderate risk.”
Scores of 10 to 12 indicate the patient is at
“high risk.”
Scores of 9 or less indicate the patient is at
“very high risk.”
Two retrospective studies on nursing homes and
facilities that utilized and enforced the Braden
scale showed an 87 percent decrease in the
Elite CME incidence of pressure ulcers [16]. Another study
demonstrated that pressure ulcers in the most
critically ill patients admitted to the intensive care
unit decreased from 33 to 9 percent [16].
In addition to the patient’s assigned risk, the
overall patient is considered, including other
major risk factors that may predispose the patient
or skew the data, such as [7]:
Fever.
Diastolic pressure below 60.
Hemodynamic instability.
Advanced age.
Collecting the history component of the
assessment
Nurses should collect a thorough history from the
patient or any appropriate caregiver or emergency
medical technician (EMT) to ensure all potential
aspects are analyzed in caring for a patient
who presents with a wound. Although a wound
may initially appear minor or a patient presents
with another complaint but has a large chronic
pressure ulcer on the sacrum, it is vital that nurses
are thorough in collecting the history. Patients
may not be forthcoming with vital information
because they don’t consider the importance of the
data or they may have forgotten it. Nurses who
ask all of the appropriate questions could find the
missing link in collecting the pieces to the puzzle.
According to the Clinical Guidelines in Family
Practice, a nurse should inquire and identify
the following questions in their history about a
wound. [82]:
1. What is the mechanism of injury?
ŠŠ It is important to assess the mechanism
of an injury because it helps to determine
the presence of foreign bodies or the
prognosis for developing an infection or
scar [18]. The type and depth of injury
may affect the healing process due to
infection, tissue damage and/or other
injury to the muscle and/or bone.
Acute wounds.
ŠŠ Bite wounds must be evaluated
for associated injuries and risk of
infection.
ŠŠ Stab wounds should be evaluated
for the depth of injury, because a
surgeon may need to be consulted
to protect the underlying
structures if they have been
penetrated or damaged in any
way.
ŠŠ Sharp objects often make
smooth cuts that penetrate deep
structures. However, a simple cut
through the skin by a sharp object
may cause minimal damage to
the surrounding tissues, and it
typically has a relatively low
risk for infection or significant
scarring [18].
ŠŠ Crushing injuries often damage
underlying tissues and can result
in fractures. In addition, they
often need to be debrided in order
to decrease the risk of infection.
ŠŠ Tearing of the skin, as occurs
Page 7
when the chin strikes the floor,
24 hours later with little risk of
produces irregular wound
infection if it is reasonably clean.
margins and damage to the
4. Where is the site of the wound?
surrounding tissues; these
ŠŠ The location of the wound may
lacerations have a moderate risk
determine the ability of the wound to heal
of infection and scarring [18].
appropriately.
ŠŠ Direct compression injuries, such
Wounds that present contaminated
as from a blow to the head, split
(“dirty”) wounds are at a high risk for
the skin, injure the adjacent soft
becoming infectious.
tissues and classically cause a
ŠŠ Signs of infection include
satellite laceration; these wounds
erythema, edema, purulent
have the highest risk of infection
discharge; a fever may or may
[18].
not be present. Typically, after a
Chronic wounds.
bite, signs of infection occur 24
ŠŠ Typically a patient with a
to 72 hours after the bite [27].
chronic wound may present with
Deep wounds are at risk of having
complications from the chronic
underlying tissue destruction and a
wound, or the patient may present
risk of contamination into the deeper
with a complaint related to a
tissues.
comorbidity.
Wounds with untidy edges typically
2. Where is the location of the wound?
heal slower and may heal with
ŠŠ The location and/or environment
disfigurement.
in which the wound occurred may
Wounds with tissue necrosis may
determine other potential problems for
be at risk for infection and delayed
the patient.
healing.
Specific location of the wound needs
It is also important to inspect the
to be identified. Where is the site
surrounding area of the wound.
of the injury? Are there any other
If the patient has any bruising on the
injuries? Always inspect the entire
head, face, abdomen, mid- or lower
body, not just one potential area and/
back with hematuria, the nurse needs
or complaint.
to notify the doctor as it may imply a
Environment in which the injury
hematoma or thrombosis [4].
occurred may alert the nurse and
If a scab or eschar develops on or
practitioner to other risk factors or
around the bruise, notify the doctor as
potential bacteria sources:
it may imply a deeper injury that may
ŠŠ Soil. If the injury and/or wound
require debridement [4].
occurred in dirty soil, then
5. What are the patient’s risk factors?
the patient is at risk for being
ŠŠ The specific risk factors for each wound
contaminated with spores of
are correlated to the specific type of
clostridium tetani (tetanus).
wound as it is implied (See Risk factors).
3. When did the patient experience the
Wound assessment
injury and/or notice the break in the skin?
Once a history has been collected and the nurse
(Essentially how old is the injury?)
is assessing the wound and any breaks in the
ŠŠ Research has demonstrated that if the
skin, the nurse needs to note and record the
injury occurred greater than six hours
size, length, depth and type of skin break. It is
from the time the patient seeks medical
important to use sterile technique [82].
care, bacteria has probably already
multiplied, putting the patient at risk for
In order to properly assess and document the
sepsis.
wound, the nurse should adhere to the following
In addition, research has
recommendations [78, 82, 86]:
demonstrated the following [18]:
1. Measure the size of the wound.
ŠŠ Wounds that closed at up to
It is important to assess and record the size,
19 hours after the injury had
length, width and depth of the wound. The
a significantly higher rate of
size is measured by multiplying the length
healing than those closed later
by the width [10]. To ensure that each nurse
(92 versus 77 percent).
and facility has standardized documentation,
ŠŠ In contrast to wounds involving
assess the wound as a clock face [41]:
other body areas, the healing
ŠŠ Example. Nurses should imagine a clock
of head wounds was virtually
and think of 12 o’clock as the patient’s
independent of time from injury
head and the 6 o’clock as the patient’s
to repair: 42 of 44 (96 percent) of
feet. Always measure the length from
wounds involving the head and
12 o’clock to 6 o’clock and the width
repaired later than 19 hours after
between 9 o’clock and 3 o’clock. The
injury were healing compared
distance from the deepest portion of
with 47 of 71 (66 percent) of all
the wound base to the skin level should
other wounds. In general, a
measure the depth.
ŠŠ Facial wound can be closed up to
ŠŠ Document the depth of the wound,
Page 8
differentiating superficial and full
thickness wounds. It is important that
nurses do not cross-contaminate between
wounds by using the same gloves,
instruments or measuring devices [96].
2. Note any wound drainage that may be
present.
The nurse needs to assess for wound
drainage, such as bleeding or exudate, and
then document the precise amount with each
assessment. It is important to document the
color, amount, consistency and odor of the
wound.
Color – The color of the wound drainage
(exudate) needs to be described. Exudate
is the fluid produced by the wound, which
consists of blood serum, serosanguineous
fluid and leukocytes [86]. Exudate
continuously bathes the wound, keeping it
moist, supplying nutrients and providing the
best condition for migration and mitosis of
epithelial cells and controlling the amount of
bacteria in the wound [86].
ŠŠ Serosanguineous appears thin and bloodtinged with amber fluid. If the wound
occurred in the previous 48 hours, this
may be a normal process. If it occurs
later, it may precede a wound dehiscence.
Serous appears thin, watery and clear
[10].
ŠŠ Purulent drainage is thin or thick
in consistency and varies in color,
depending upon the potential source.
Creamy yellow implies a
staphylococcus infection.
Greenish blue pus with a fruity odor
implies pseudomonas.
Beige pus with a fishy odor implies
proteus.
Brownish pus with a fecal odor
implies aerobic coliform and
bacteroides that may occur as a
complication after any intestinal
surgeries.
ŠŠ Bloody drainage is thin and bright red.
Amount – The nurse needs to measure
any drainage by describing the amount that
saturates the dressing and any amount that
may be collected in a drain. The amount of
drainage should be measured in milliliters
(ml) at least every shift or more frequently,
depending upon the amount of drainage.
Consistency – The consistency of the wound
drainage should be assessed and documented.
Is it thick, thin or tenacious?
Odor – If there are any signs of infection
within the wound, it needs to be addressed
before the wound can begin to heal [48, 96]:
ŠŠ Fruity smells suggest a staphylococcus
organism.
ŠŠ Foul (fecal) odor suggests gram-negative
bacteria (escherchia coli).
3. Describe the appearance of the wound
tissue, edges and color.
The appearance of wound tissue depends
Elite CME
upon the balance of granulated and necrotic
tissue [86]:
ŠŠ Wound tissue – The surrounding tissue
needs to be described as it may imply the
patient needs a referral for a debridement
to remove dead tissue [48].
Viable, healing wounds appear
healthy when it is bright, beefy red,
shiny and granular with a velvety
appearance, implying the presence of
granulated tissue.
ŠŠ Granulation tissue is the growth
of small blood vessels and
connective tissue to fill in full
thickness wounds [10].
ŠŠ Epithelialization is the process
of epidermal resurfacing and
appears as pink or red skin. In
partial thickness wounds, it can
occur throughout the wound bed
as well as from the wound edges.
In full thickness wounds, it
occurs from the edges only [10].
ŠŠ Slough tissue is yellow or cream colored
with a puslike consistency that occurs
in the presence of moisture and bacteria
(exudative or devitalized tissue) [10]:
Non-adherent, yellow slough is a
thin, mutinous substance that is
scattered throughout the wound bed
and is easily separated from wound
tissue.
Loosely adherent, yellow slough is
thick, stringy, clumps of debris that
are attached to wound tissue.
ŠŠ Necrotic or eschar tissue is thick and
it appears black or dark brown in color.
Eschar tissue can be either [10]:
Soft adherent and appear as soggy
tissue that is firmly attached in the
center or the base of the wound.
Firmly adherent hard/black eschar,
crusty tissue that is
strongly attached to the wound base
and edges (like a hard scab).
ŠŠ Poorly healing wound tissue appears as
pale pink or blanched to dull, dusky red
color depending upon the source [10].
Poor arterial wounds appear pale with
immature granulated tissues.
Poor venous wounds appear with
a deep red color, reflective of
deoxygenated blood beneath the ulcer
surface.
If the patient has slough or necrotic
tissue, the wound healing process is
impeded because both conditions prevent
granulation and epithelialization from
occurring [86]. In order for the wound to
begin healing, the patient needs to be free
from slough and eschar, and the wound
should be moist with red-pink budding
granulated tissue [86].
ŠŠ Wound edges – The wound edges should
be inspected for contraction (gradual
healing from the edges to the center of
the wound) [86].
The edges may be described using
the following terms recommended by
Dr. Barbara Bates-Jensen (a doctoral
prepared nurse who has implemented
numerous research and clinical tools
for practice to improve the quality of
skin care). [10]:
ŠŠ Indistinct, diffuse – Unable to
clearly distinguish wound outline.
ŠŠ Attached – Even or flush with
wound base; no sides or walls
present; flat.
ŠŠ Not attached – Sides or walls are
present; floor or base of wound is
deeper than edge.
ŠŠ Rolled under, thickened – Soft to
firm and flexible to touch.
ŠŠ Hyperkeratosis – Callouslike
tissue formation around wound
and at edges.
ŠŠ Fibrotic, scarred – Hard, rigid to
touch.
Note if there is any erythema,
tenderness, maceration or cellulitis.
ŠŠ Maceration is exhibited when the
wound appears pale or white in
color. Maceration occurs when
the drainage from the wound has
extended contact with the healthy
tissue around the wound [86].
ŠŠ Cellulitis may imply the
patient’s inability to resist
infection if proper measures
are not implemented to
alleviate the pressure [48]. (See
Complications: Cellulitis for
treatment recommendations).
ŠŠ Skin color – Observe for any erythema
or ecchymosis around the injured area by
blanching the area.
4. Assess and document the circulation,
sensation and movement distal to the
wound.
It is important to assess for arterial disease,
because it may actually be the cause of the
wound and can impede the ability of the
wound to heal [48]. A patient with arterial
deficits should be referred to a surgical
specialist immediately [48].
ŠŠ If there is a wound or skin breakdown
noted on any of the patient’s extremities,
the nurse needs to assess the distal pulse
and blanch the skin, then assess distal
sensation [48].
5. Assess and document the range of motion
(ROM) and strength of the affected and/or
adjacent extremities.
The ROM needs to be assessed against
resistance on all parts surrounding the wound
site [82].
Due to the complexity of wounds, the
enormous complications and consequences
to patients and indeed the health care system,
it is imperative to properly document the
wound completely to prevent further damage
and to prevent lawsuits.
Elite CME Wound classification
Over the years, various organizations have
developed guidelines to ensure health care
providers are able to describe and classify various
wounds into specific categories. The classification
of wounds is unique to the specific wound, but
there are common terms that are used, depending
upon the layers of skin that are involved [19, 41]:
Superficial or partial thickness wounds
involve only the epidermis layer, such
as lacerations, skin tears, first-degree
burns, abrasions and shallow ulcerations.
Superficial/partial thickness wounds heal by
re-epithelialization, the production of new
cells into the basal layer of the dermis. The
typical healing takes approximately five to
seven days.
Full-thickness wounds involve the
epidermis and dermis layers of the skin and
may even extend to the muscle and bone.
Typical examples include deep lacerations,
second- and third-degree burns, various
types of ulcers and surgical and traumatic
wounds. Full-thickness wounds heal through
granulation by removing damaged tissue. Full
thickness pressure ulcers are often covered
by a layer of black, gray or brown nonviable,
denatured collagen called eschar [41]. In the
early stages of healing, eschar is dry, leathery
and firmly attached to the wound surface.
During the inflammatory process, the eschar
begins to lifts and separates from the tissues
beneath, which promotes a great site for
bacteria to grow. If the bacteria proliferates,
enzymes will be released, which softens
necrotic tissue providing a softer, yellow
appearance [41].
1. Burns.
Burns are classified according to the depth
and thickness of the wound [19,72]:
ŠŠ First-degree are superficial, localized
injuries or destruction that involves the
epidermis, typically by direct contact
such as a chemical spill or an indirect
cause, such as sunburn.
ŠŠ Second-degree burns are partial thickness
burns that involve the epidermis and part
of the dermis. They typically leave part of
the dermis intact. The degree of the burn
is progressively deeper than first-degree,
in which the hairs are easily extracted
and/or absent, sweat glands are less
visible, and the skin appears smoother
[7].
ŠŠ Third- and fourth-degree burns are
full thickness injuries that involve the
epidermis and dermis and extend into the
subcutaneous tissues.
Another burn classification is the
involvement of the burn injury based upon
the percentage of the total body surface area
that is damaged. This is estimated by the Rule
of Nines chart to calculate the percentage of
body surface area (BSA) [5]. First-degree
burns are not analyzed for the percentage
of total body surface because they do not
represent significant injury [72]. Research
Page 9
has demonstrated that the majority of burns
involve less than 10 percent of the total body
surface area [7]. But the depth and involved
area of injury determines the prognosis and
mortality risks for the patient. Over the years,
the three major risk factors for mortality from
a burn include [57]:
ŠŠ Age greater than 60.
ŠŠ Percentage of total body surface area.
ŠŠ Inhalation injury.
ŠŠ
The mortality calculation is based upon the
Baux score formula [57]:
Age plus percentage area burned equal
the percent mortality.
Example: 50 years old plus 20 percent
burned equals a 70 percent mortality risk.
2. Pressure ulcers.
In the 1980s, the National Pressure Ulcer
Advisory Panel (NPUAP) developed a
national staging system for pressure ulcers.
In 2007, the NPUAP revised its guidelines,
including the original four stages and
adding two stages on deep tissue injury and
unstageable pressure ulcers. The NPUAP’s
updated stages reflect an accumulation of
research developed over six years [48, 67].
Pressure ulcers are classified in the following
stages [19, 53, 67, 78] (See Table 1, at the
end of this chapter):
ŠŠ Suspected deep tissue injury:
Presents as a purple or maroon localized
area of discolored intact skin or bloodfilled blister due to damage of underlying
soft tissue from pressure or shear. The
area may be preceded by tissue that is
painful, firm, mushy, boggy, warmer or
cooler as compared to adjacent tissue.
ŠŠ Stage 1 ulcers:
Presents as a “nonblanchable”
erythematous patch of skin. It is an
observable pressure related to an
alteration of the intact skin. The key
is the skin remains intact, but once the
pressure has been alleviated, the skin
remains erythemic, pink, red and/or
mottled in appearance [57]. The NPUAP
convened a task force to review the
definition of a Stage I pressure ulcer in
1998. At that time it elaborated on the
definition to address individuals with
darkly pigmented skin [65]:
A Stage 1 pressure ulcer is an
observable pressure-related alteration
of intact skin whose indicators as
compared to the adjacent or opposite
area on the body may include
changes in one or more of the
following:
ŠŠ Skin temperature (warmth or
coolness), tissue consistency
(firm or boggy feel) and/or
sensation (pain, itching).
ŠŠ The ulcer appears as a defined
area of persistent redness in
lightly pigmented skin, whereas
in darker skin tones, the ulcer
may appear with persistent red,
ŠŠ
ŠŠ
ŠŠ
blue or purple hues.
Stage 1 pressure ulcers can be
difficult to assess in patients with
darkly pigmented skin [94].
Stage 1 pressure ulcers typically heal
in 14 days.
Stage 2 ulcers:
A partial thickness skin loss that involves
the epidermis, dermis layer and/or both.
They are superficial ulcers that
appear as a crack, abrasion, blister
or shallow crater with an erythemic
wound bed, without slough. Necrotic
tissue may overlie the pressure ulcer
[57]. The NPUAP (2007) provides
further explanation on stage 2
because the organization wants to
ensure that nurses do not confuse
or describe skin tears, tape burns,
perineal dermatitis, maceration or
excoriation as a Stage 2 ulcer [67].
Typically, Stage 2 ulcers heal within
a few weeks, or approximately 45
days.
Stage 3 ulcers:
A full thickness skin loss that involves
damage or necrosis of the subcutaneous
tissue. It may even extend to, but not
through, the underlying fascia (tendons
or bones).
Appears as a distinct ulcer margin,
a deep crater with or without
undermining of adjacent tissue.
Slough may be present, but should
not obscure the depth of tissue loss
and it may include tunneling.
Typically they heal within a few
months, or approximately 90 days.
Stage 4 ulcers:
Presents as a full thickness skin loss with
extensive destruction, tissue necrosis and/
or damage to muscle, bone or support
structures, such as the tendons or joint
capsules. In addition, there may be
tunneling, slough and eschar associated
with stage 4 ulcers.
Typically healing takes many months
or longer depending upon the depth
of destruction, necrosis and/or
damage to the bones.
During the third and fourth stages,
the patient is at very high risk of
enduring complicated infections that
may cause sepsis. Actor Christopher
Reeve died a few years ago related to
complications from a pressure ulcer.
Unstageable ulcers:
Presents as a full thickness tissue loss in
which the base of the ulcer is covered by
slough (yellow, tan, gray, green or brown)
and/or eschar (tan, brown or black) in the
wound bed. The NPUAP states that an
ulcer cannot be staged if there is slough
and eschar on the top of the wound; it
needs to be removed to expose the base
of the wound to allow the nurse and
practitioners to visualize the true depth
and stage of the wound. However, if
there is eschar (dry, adherent, intact and
without erythema) on the heel, it should
not be removed, according to the NPUAP
guidelines, because it serves as the body’s
natural biological cover [67].
It should be noted, there are some
sites that identify a Stage 5 as a
closed cavity communicating through
a small sinus [57]. However, nurses
should adhere to the NPAUP staging
system and their own employers’
policies to ensure compliance and
unity in the profession.
Once the wound has been staged,
it needs to be reassessed frequently
to monitor for any improvement
or deterioration of the wound.
Depending upon the venue in which
the patient is being seen, this will
determine the frequency in which the
pressure ulcer is re-evaluated.
ŠŠ If the patient is in the hospital
setting, the patient will be
reassessed preferably every shift,
or a minimum of every day. It
is important to adhere to the
hospital policy as it may differ at
each facility.
ŠŠ If the patient is being followed
and/or treated in the community,
the wound needs to be reassessed
at least weekly [94].
Although there are many variables that
contribute to the risk of developing
pressure ulcers, it can be alleviated
with safe, diligent care. This involves
recognizing the risk factors and turning
all patients at a minimum of every two
hours and the use of floatable devices
and/or alternating pressure mattresses.
3. Skin tears.
Skin tears are classified based upon the
Payne-Martin classification system for skin
tears [19]:
ŠŠ Category 1.
Skin tear without tissue loss.
Linear type: epidermis and dermis
have been pulled apart.
Flap type: epidermal flap completely
covers the dermis to within one
millimeter of the wound margin.
ŠŠ Category 2.
Skin tears with partial tissue loss.
Scant tissue loss: 25 percent or less of
the flap is lost.
Moderate to large tissue loss: more
than 25 percent of the epidermal flap
is lost.
ŠŠ Category 3.
Skin tear with complete tissue loss.
Epidermal flap is present.
Signs and symptoms of the most common
wounds
Depending upon the type of wound, patients will
present with symptoms that help practitioners and
nurses differentiate between the diagnosis and
Page 10
Elite CME
treatment modalities. Therefore, it is imperative
to ensure a thorough assessment is implemented,
to avoid inappropriate and/or ineffective care.
1. Abrasions, excoriations, or scrapes.
An abrasion typically presents as multiple
lines of scraped skin with minuscule bleeding
noted on and/or around the scratches.
2. Bites.
The physical presentation of a bite will be
dependent upon the extent and depth of the
bite and can be a puncture, laceration or
avulsion (tissue is torn away from the body).
It is important to do further investigation
depending upon the source of the bite and the
appearance of the injury in order to prevent
complications such as infection, bone and
tissue injury and/or osteomyelitis.
3. Bruising.
A bruise will present as ecchymosis that
appears as a purplish, flat area that occurs
when blood leaks out into the top layers of
skin [73].
4. Burns.
Due to the various types of burns that may
occur, there are various signs and symptoms
that the patient may present with upon
admission. Burn injuries are classified
depending upon the depth of the tissue injury
and involvement of the skin and surrounding
organs [72]:
ŠŠ Superficial partial thickness burns:
First-degree burns – The symptoms
of a first-degree burn are erythema,
slight edema and pain. In more
severe first-degree burns, the patient
may exhibit chills, headache, local
edema, nausea and vomiting [5].
First-degree burns typically heal in a
few days and rarely leave any scars,
and they are nonlife-threatening. The
most common first-degree burns are
sunburns, which may cause blisters,
although blisters do not occur
initially [57]. If they do occur, then
the wound is classified as a seconddegree burn [57].
Second-degree burns are also
known as superficial partial thickness
burns. Second-degree burns appear
erythemic, tan or white in color
and are blistered. The blisters are
typically thin-walled, fluid-filled
blisters that develop within a few
minutes of injury [5]. Once the
blisters break, the nerve endings
become exposed to the air, and pain
and tactile responses remain intact
[5]. Second-degree burns typically
take two weeks to several months to
heal and may leave scars. The most
common second-degree burns are
sunburns and scalds.
ŠŠ Full thickness burns.
Third- and fourth-degree burns
involve the epidermis, dermis and
often the deeper tissues are destroyed,
including blood vessels. Because the
dermis is completely destroyed, the
skin regenerates only from the edges
of the wound. The wound appears
pale white, cherry red or black. The
tissue is often dry with necrotic areas
[19].
5. Lacerations or cuts.
Lacerations typically appear with bleeding,
pain, numbness, and/ or swelling at the
injured site.
6. Perineal skin breakdown may appear as one
or all of the following symptoms: erythema,
edema, oozing, vesiculation, crusting and/or
scaling in the groin, perineum and buttocks
[66].
7. Pressure ulcers.
Pressure ulcers typically develop over a bony
prominence due to continuous pressure on the
tissue, which occludes the blood supply [53].
The most common sites of pressure ulcers,
which account for 95 percent of all pressure
ulcers, include the following areas that are
usually on the lower part of the body [51, 53,
94]:
ŠŠ Sacrum (36 percent of cases, typically on
the lower back).
ŠŠ Greater trochanter.
ŠŠ Ischial tuberosity.
ŠŠ Heel (30 percent).
ŠŠ Lateral malleolus.
ŠŠ In addition, there are other areas to
consider where pressure ulcers may
occur, such as on the occiput, behind the
ears, and on the elbows [57]. Anytime a
patient is wearing oxygen, it is important
to assess the back of the ears because
if the oxygen apparatus is on too tight,
pressure ulcers can occur behind the ears
[41].
If the pressure is alleviated in a few hours,
there will be erythema noted initially, which
resolves without any lasting tissue damage
[53]. If the pressure continues without
relief and/or a change in position, then
the endothelial lining becomes disrupted
with platelet aggregation, forming micro
thrombi that block the blood flow and cause
anoxic necrosis of the surrounding tissues
[53]. The NPUAP stage will determine the
physical findings on the patient (See Wound
classification).
8. Punctures.
Puncture wounds usually present with mild
bleeding and pain at the site. The source of
injury may point to further problems and/ or
damage, such as small pieces of glass in the
skin [29].
9. Skin tears.
A skin tear presents as a tear, from no tissue
loss to a flap depending upon the severity.
(See Wound classification: Skin tears).
10. Surgical wounds.
The majority of surgical wounds will close by
Elite CME primary intention in which the surgical site
will demonstrate granulated tissue without
signs and symptoms of infection. If the
wound was closed by secondary or tertiary
intention and/or infection prevails, the site
may have erythema, drainage and odor.
11. Ulcers.
ŠŠ Diabetic. Diabetic foot ulcers involve
infectious symptoms of erythema,
warmth, swelling or induration and/or
pain or tenderness [38] (See Table 2, at
the end of this chapter).
ŠŠ Leg ulcers.
Venous ulcers can be present
anywhere between the knee and
ankle, with the medial and lateral
malleolus being the most common
sites. Characteristics of venous
wounds are as follows [76]:
ŠŠ The wound margins tend to be
large and irregular.
ŠŠ The wounds are superficial.
ŠŠ The wound beds vary in
appearance from ruddy, beefy
red to a superficial fibrinous
gelatinous necrosis that may
occur suddenly with healthyappearing tissue underneath.
ŠŠ The wound is painless. (See Table
3, at the end of this chapter)
Arterial ulcers are present anywhere
on the leg, distal to the impaired
arterial supply. Characteristics of
arterial wounds are as follows [76]:
ŠŠ The wound margins are even,
sharply demarcated and punched
out.
ŠŠ The wound may be superficial or
deep.
ŠŠ The wound beds may be pale,
gray or yellow with no evidence
of new tissue growth.
ŠŠ The wound is painful. (See Table
4, at the end of this chapter)
Diagnosing wounds
Proper diagnosis is the key to proper
wound healing. If the specific wound is not
properly diagnosed, then the patient may
receive ineffective treatment modalities, thus
exacerbating the injury and the potential ability
of the wound to heal. In addition, the NPUAP
has noted that the most challenging wounds
to diagnose are chronic wounds on the lower
extremities, as they may be related to neuropathy,
ischemia, venous hypertension and/or pressure
[48].
Once an injury or wound has been established,
the primary care provider and/or provider
responsible for the care of the wound may
order certain labs and/or diagnostic tests to
help determine the degree of damage and or
underlying factors that may affect the healing
process. The following laboratory, cultures and/or
diagnostic tests may be implemented depending
on the site and depth of injury, source of injury
and ineffective healing modalities [78]:
Page 11
Laboratory
Basic metabolic profile (BMP) to assess the
electrolytes and any renal insufficiency. The
blood glucose level is important to monitor
for all diabetics or undiagnosed diabetics
since poor glucose control affects the wound
healing.
A coagulation study to evaluate for
coagulation abnormalities, especially if a
deep wound excision is required.
Complete blood count (CBC) to assess for
leukocytosis, anemia and thrombocytopenia.
ŠŠ Leukocytosis is elevated white
blood cells (WBC) and indicates an
inflammatory response [19].
ŠŠ Anemia is exhibited by low hemoglobin
and hematocrit, and depending upon
the actual cause of the anemia, other
factors such as the mean corpuscular
volume (MCV) and mean corpuscular
hemoglobin (MCH) may be altered. It
is important to identify anemia in any
patient with a wound because it will slow
down the healing time due to the lack of
oxygenation and perfusion [19].
ŠŠ Thrombocytopenia is exhibited by a
low platelet count that may be caused
by fever, infection and/or poor wound
healing.
C-reactive protein (CRP) to assess for any
inflammation may be ordered as a baseline
and to monitor the effectiveness of treatment
[19]. However, the CRP is not a specific
test for any certain disease, but a marker to
evaluate an inflammatory process in the body.
Protein, albumin, prealbumin, and transferrin
to assess the patient’s nutritional status.
ŠŠ Serum prealbumin is sensitive for
relatively acute malnutrition because
the half-life is two to three days (rather
than 21 days for albumin). If a patient
has a serum prealbumin level less than
seven grams per deciliter (dl) it indicates
severe protein calorie malnutrition.
Therefore, prealbumin reflects the
recent protein consumption, whereas
the albumin level reflects the long-term
protein consumption [17]. If a patient
is undernourished or malnourished,
they should be referred to a dietician
immediately because it is associated
with poor clinical outcomes, including
mortality [17].
ŠŠ A combination of a low lymphocyte
count, less than 1,500, coupled with an
albumin count less than 3.5 grams per
deciliter is indicative of malnutrition,
which delays overall wound healing [71].
Cultures – In order to assess for any fungi,
bacteria or viral pathogens isolated in the skin
area of concern, blood and wound cultures are
taken to determine the most appropriate therapy.
One should not assume that just because a wound
is open that it is infected. But it would always be
contaminated [23].
Contamination is defined as the presence of
organisms without any clinical signs and/
or symptoms of infection [23]. All chronic
wounds are colonized with bacteria at
varying degrees [33].
Wound infection is a contamination with
a pathogenic organism that cannot be
controlled by the body’s immune defenses.
It is exhibited by inflammation, induration,
erythema, odor and exudate [21].
Therefore, a wound culture will be implemented
to assess for various potential sources of the
infection (bacterial or fungal).
Fungal infections – The skin area of concern
should be gently scraped from the skin lesion
then sent to the laboratory for analysis. If it is
a deeper area of concern, then the patient will
require a punch biopsy [23].
Pressure ulcers – If the patient has a
pressure ulcer, swab cultures will only
demonstrate surface contaminants, rather
than providing valid, reliable results on the
specific bacteria colonized within the ulcer.
Therefore, it is recommended that a needle
aspiration should be utilized to identify the
infecting organism [16]. Once the wound has
been identified, it is imperative to assess the
type of bacteria localized in the wound or
found systemically in the body. Interestingly,
a positive wound culture does not necessarily
confirm a wound infection [78].
Diagnostic tests – In addition to laboratory
data and cultures, the following diagnostic
tests may also be ordered [78]:
ŠŠ Plain radiography (X-rays), CAT scan
(CT) and magnetic resonance imaging
(MRI) to assess for any underlying
abnormalities and/or foreign bodies. It
is important to obtain an X-ray with any
accidental injury or a patient presenting
with an incomplete history because a
patient may have a wound infection or
injury caused by a foreign body, which
prevents the healing process because
of debris and retained fragments [78].
Therefore, it is imperative to identify any
foreign bodies before infection or injury
occurs.
In addition, X-rays may be ordered
for any significant animal bite, such
as a dog bite, since many dog bites
induce crushing injuries and damage
to the surrounding tissues [6].
Research has demonstrated that the
jaw of a dog has the ability to exert
200 to 400 pounds per square inch
(psi) during a bite [6].
If a diabetic foot ulcer is speculated,
radiographs of the foot should be
ordered to rule out osteomyelitis
(bone infection) [38].
ŠŠ Vascular ultrasonography (US) to
evaluate for aneurysmal disease or
venous occlusion.
ŠŠ Nuclear medicine (NM) bone scan to
assess for osteomyelitis.
ŠŠ Ankle/brachial index (ABI) is completed
to evaluate the vascular system in a
patient with a potential diagnosis of
venous or arterial ulcers [57]. Once
arterial disease is diagnosed, ABI should
be implemented every three to seven
months [30]. The ABI results are as
follows [76]:
0.9 to 1 is normal.
0.75 to 0.9 is moderate disease.
0.5 to 0.75 is severe disease. If the
results are between 0.6 and 0.8,
the patient should be referred to an
advanced wound clinician [30].
Below 0.5 implies limb-threatening
disease, and the patient should be
referred to a vascular lab for further
investigation [85].
Biopsies – They may be done to assess for
potential complications of certain wound injuries.
The most common type of biopsy is a punch
biopsy in which a small, circular instrument
punches a diameter from 2 to 6 millimeters (mm)
[41]. For instance, a bone biopsy is the gold
standard for diagnosing osteomyelitis [94].
Generalized treatment of wounds
In order to properly treat a wound, it is
imperative that the patient and the wound are
properly assessed in their entirety. There are
enormous variables that intertwine and may affect
the healing process; this reiterates the important
aspect of treating the patient holistically because
individual patients may have various risk factors,
co-morbidities and lifestyles that may affect the
healing process.
Due to the complexity of wound care, each of the
treatment modalities are discussed and elaborated
upon under each specific wound type in the
next section, (Specific treatment of wounds).
In order to maintain overall homeostasis and
wound healing, the following factors, including
tissue perfusion, nutrition, pain, wound cleaning,
dressing changes, sutures and a tetanus shot
need to be integrated and/or considered in the
treatment plan for any wound.
1. Antimicrobials.
There is a plethora of bacterial or fungal
sources for causing infection, but one of
the most prevalent and most dangerous is
methicillin-resistant staphylococcus aureus
(MRSA). The IHI has also added MRSA
as among its goals to eradicate with its 5
Million Lives campaign [42] (See Wound
complications).
If the patient has a wound infection, it may
require surgical debridement and appropriate
systemic antibiotic therapy, depending on
the type of bacteria [78]. Typically, topical
antiseptics are avoided because they interfere
with wound healing [78].
2. Debridement.
Debridement is a method of treatment
to clean or remove necrotic, dead tissue
so that granulation can occur to improve
wound healing. There are various types of
debridement [8,93]:
ŠŠ Autolytic debridement involves the use
of the body’s own enzymes and WBCs to
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Elite CME
rehydrate, soften and finally liquify the
eschar and slough.
Achieved with the use of occlusive
or semi-occlusive dressings that
maintain fluid in contact with
necrotic tissue. However, it can also
be achieved with hydrocolloids,
hydrogels and transparent films.
Nurses should refrain from using
an occlusive hydrocolloid as it may
promote aerobic bacteria growth [95].
Best used in the treatment of stage 3
and 4 pressure ulcers.
ŠŠ Enzymatic debridement involves the use
of chemical enzymes as a fast-acting
product to slough off necrotic tissue.
Best used in the treatment of any
wound with necrotic debris or eschar
formation.
Disadvantages to utilizing enzymatic
debridement are the expense and
that it may cause inflammation or
discomfort at the site [95].
ŠŠ Mechanical debridement involves initial
treatment with a dressing, then manually
removing the dressing mechanically.
Hydrotherapy is an example of
mechanical debridement.
A disadvantage to using mechanical
debridements is that it can traumatize
healthy or healing tissue when
the dressing is removed, therefore
inducing further pain for the patient.
Another side effect to mechanical
debridement is the potential
development of maceration [95].
ŠŠ Surgical debridement involves surgery
under anesthesia to remove necrotic or
infected tissues.
After a patient undergoes debridement, the
nurse should apply a moist sodium chloride
dressing or isotonic sodium chloride gel
(Normlgel, IntraSite gel) or a hydrocolloid
paste (DuoDerm). In order to achieve optimal
wound coverage, it is imperative to perform
wet-to-dry dressings, which reinforce the
autolytic debridement as it absorbs exudate
and protects the surrounding healthy skin. A
polyvinyl film dressing (Op-Site, Tegaderm)
that is semipermeable to oxygen and moisture
and impermeable to bacteria is a good choice
for wounds that are neither very dry nor
highly exudative [77].
3. Dressings.
Nurses many times must ask:
ŠŠ Do I apply a dressing to the wound?
ŠŠ If so, what type of dressing do I apply?
ŠŠ How often do I need to change the
dressing?
Nursing care for wounds is time-consuming
because of the complexity of the wound
and the frequency of dressing changes,
especially if the wound requires a sterile
field. In addition, there are numerous types of
dressings that may be applied to a wound and
various techniques that can cause confusion
among nurses. The majority of dressings need
to be changed daily and when they become
wet or dirty to reduce the risk of infection and
to promote the healing process [54].
Dressing changes are initiated and applied
to accelerate the healing process by ensuring
that unwanted debris stays away from the
wound while creating a barrier between
the body and environment [21]. On the flip
side, many researchers recommend keeping
a dressing in place for several days as it
aides in the early healing process because
the wound is left undisturbed and the wound
remains moist. This helps regulate the body
temperature, which in turn provides stability
in the wound [23].
ŠŠ Dressing change techniques. It is
important for a nurse to adhere to the
appropriate dressing change technique
to prevent cross-contamination and
infection.
Sterile technique involves stringent,
diligent care from the nurse or health
care providers to reduce exposure to
microorganisms and keep the area as
free from microorganisms as possible
[33]. It is important to adhere to the
2005 Wound Ostomy Continence
Nursing (WOCN) society’s
recommendations for sterile dressing
change techniques [33]:
ŠŠ Meticulous hand washing.
ŠŠ Use a sterile field, including
sterile gloves, when touching or
using any equipment in or around
the wound site and during the
application of the dressing.
ŠŠ Clean technique may also be referred to
as a “non-sterile” procedure that involves
strategies used in patient care to reduce
the overall number of microorganisms
or to prevent or to reduce the risk of
transmitting microorganisms from one
person to another [33]. The WOCN
elaborates that clean technique involves
[33]:
Meticulous hand washing.
Maintaining a clean field with clean
gloves and sterile instruments.
ŠŠ Aseptic technique involves the
prevention of the transfer of organisms
from one person to another by keeping
the microbe count to a minimum [33].
ŠŠ No-touch technique is a method of
changing dressings on the surface without
directly touching the wound or any
surface that might come in contact with
the wound [33].
Regardless of the type of wound, nurses
are required to wash their hands before
assessing or touching a wound and after any
encounter with a patient to reduce the risk of
nosocomial infections.
ŠŠ Types of dressings – It is important
for the nurse to understand the types
and purpose of dressings to ensure the
Elite CME ideal and most appropriate dressing is
applied to a wound for adequate healing.
It is important to refrain from using
any dressing when a wound initially
occurs as it may cause more harm than
benefit to the wound. Another factor to
contemplate, according to World Wide
Wound (2008) [80]:
A dressing that is ideally suited in the
early stages of treatment of infected,
malodorous or necrotic wounds
may not be appropriate for the later
stages of healing. For example, sterile
maggots have proven to treat wounds
rapidly and cost-effectively, but some
researchers suggest maggots should
not be applied to all types of wounds
throughout the entire healing process.
Similarly, a dressing that promotes
angiogenesis and the production of
granulation tissue may not be equally
suitable for the final epithelialization
stage of wound closure.
To complicate matters further, there
is no protocol for a specific dressing
application for all wounds at specific
stages. The ideal dressing is dependent
upon the type and severity of the wound
to promote adequate healing. Research
has demonstrated that failure to utilize
the most appropriate dressings will result
in a delay in the healing process [23, 41,
50].
ŠŠ All absorbent combined dressings
are large cotton-filled dressings that
are typically used to cover the primary
dressing, such as gauze or hydrophillic
dressing for extra protection. It may also
be used over an intact surgical wound.
Examples include surgipad or an
ABD dressing.
ŠŠ Alginates are soft, nonwoven fibers
that are derived from brown seaweeds
that are available in a pad or rope form.
Alginates are indicated for absorption and
protection of the wound.
The advantages of alginates are
that they are highly absorbent,
biodegradable, have easy application,
can be used as a packing in deep
wounds and can be used for infected
wounds. Alginates are also beneficial
for wounds with copious exudate.
The disadvantage of alginates are that
they require secondary dressings to
keep them secure, and they can cause
desiccation of the tissue if drainage is
minimal.
The frequency of dressing changes
should be when the dressing is
saturated or every three to five days.
Examples of alginates are pads and
ropes.
ŠŠ Biological dressings are indicated after
eschar removal, as a protector, to treat
burns, assess skin grafts and for dormant,
nonhealing wounds that do not respond to
other topical therapies.
Page 13
ŠŠ
ŠŠ
ŠŠ
ŠŠ
ŠŠ
The advantages of biological
dressings are they are the most
natural wound covering, they reduce
pain, conform to uneven wound
surface, act as a catalyst for healing
and they are an alternative option for
autografts.
The disadvantages of biological
dressings are that they require
secondary dressings for security, and
they are very expensive.
Cotton gauze dressings – For years,
cotton gauze has been the most common
type of dressing used because it has
impeccable abilities to absorb blood and
tissue fluid during and after surgery.
A disadvantage for cotton gauze
dressings is the fiber in the gauze can
be lost in the product, thus impairing
the ability of the wound to heal
appropriately [79].
Foams are indicated for absorption and
protection. Foam dressings can absorb
an abundance of fluid, and are useful in
the earlier stages of healing when the
drainage is the most abundant. Another
advantage of the foam dressing is that
they are comfortable and gentle to the
skin and can be left in place for several
days.
In comparing foams and cotton gauze
dressings, foam dressings are more
attractive than the simple cellulosebased material in cotton gauze and
eliminate the potential problem of
fiber loss [79].
Examples of foam dressings: Allevyn
adhesive dressings, Lyofoam and
Polymen nonadhesive dressings.
High bulk gauze bandages are primarily
used for packing large wounds that are
healing from secondary intention.
Examples of high bulk gauze
bandages are Fluffs.
Hydrocolloidal wafers (adhesive wafer)
dressings are indicated for debridement,
absorption and protection. The
hydrocolloidal dressings are formulated
with elastic, adhesives and gelling agents
that help keep the area moist to promote
wound healing.
Another advantage of the
hydrocolloidal wafers is they only
need to be changed every five to
seven days.
Examples of hydrocolloidal wafers
are DuoDerm and Tegasorb.
Hydrogel dressings are indicated for
debridement, absorption and protection.
In clinical practice, hydrogels usually
are used to rehydrate eschar in order
to promote autolytic debridement. The
majority of hydrogels are applied directly
to the wound, then a secondary dressing
is applied over the hydrogel (such as a
foam or gauze) to maintain the required
moisture level for wound healing.
Examples are DuoDerm Hydroactive
wound gel and Tegagel.
ŠŠ Hydrofiber is an absorptive textile fiber
pad that is also available as a ribbon for
packing of deep wounds. The unique
component of hydrofiber is it is covered
with secondary dressings. Hydrofiber
works by combining with the wound
exudate to produce a hydrophilic gel,
such as Aquacel-AG that contains a 1.2
percent ionic silver solution that has
strong antimicrobial components against
many organisms, including methicillinresistant staphylococcus aureus and
vancomycin- resistant enterococcus [77].
ŠŠ Hydrophobic occlusives are nonadhering
dressings that protect the wound from air
and moisture-borne contaminations.
Examples are petrolatum gauze.
ŠŠ Hydrophilic polyurethane films are
very permeable to water vapor and
thus permit the passage of a significant
quantity of the aqueous component
of exudate from the wound to the
environment by evaporation.
The advantages of hydrophilic
dressings are they allow the drainage
to penetrate the dressing. However
they are nonadherent.
An example is an oil-based gauze
that is typically used on open ulcers
or granulating wounds. Another
example is a Telfa pad, which is
optimal for simple, closed, stable
wounds.
ŠŠ Transparent films are indicated for
debridement, protection (partial thickness
lesions) and as a secondary dressing.
These are useful for clean, dry wounds
having minimal exudate, and they
also are used to secure an underlying
absorptive material. They are used for
protection of high-friction areas and areas
that are difficult to bandage such as heels
(also used to secure IV catheters) [77].
The advantage of transparent films is
that they are highly elastic dressings
that adjust exceptionally well to the
body.
Examples include Tegaderm and
Op-site.
According to Medscape (2007), there were
over 99 studies conducted between January
1990 and June 2006 monitoring the efficacy
of modern dressings in healing acute and
chronic wounds by secondary intention. The
studies revealed the following [11]:
ŠŠ The 99 studies were composed of 89
randomized controlled trials, three metaanalyses, seven systematic reviews and
one cost-effectiveness study.
ŠŠ Evidence demonstrated that hydrocolloid
dressings were superior to saline gauze
or paraffin gauze dressings for complete
healing of chronic wounds, and alginates
were better than other modern dressings
for debriding necrotic wounds. When
compared with other traditional dressings
or a silver-coated dressing, respectively,
hydrofiber and foam dressings reduced
healing time of acute wounds.
ŠŠ Types of dressing changes [50].
Dry-to-dry dressings are used for
wounds closing by primary intention.
ŠŠ The advantage is it provides good
wound protection, absorbs any
drainage and it provides pressure
to the area if needed.
ŠŠ The disadvantage is the dressing
adheres to the wound surface
once the drainage dries, thus
impeding wound healing during
the removal process because the
granulated tissue is removed, and
it causes pain for the patient.
Wet-to-dry saline dressings are used
for untidy or infected wounds that
must be debrided or are closed by
secondary intention.
ŠŠ The advantage is it eliminates
dead space because the gauze is
saturated with sterile saline and/
or an antimicrobial solution. The
wet dressing is then covered with
a dry dressing.
Wet-to-wet dressings are used on
clean, open wounds or on granulating
surfaces. Similar to the wet-to-dry
type of dressing change, sterile saline
or antimicrobial agents may be used
to saturate the dressing.
ŠŠ The advantage is it provides a
physiologic warm environment
that enhances local healing and
provides comfort to the patient.
ŠŠ The disadvantage of this dressing
is that the surrounding tissues
can become macerated, thus
increasing the risk of infection
and frequent bed linen changes.
For years, dry-to-dry dressings were
the mainstay therapy, but more recent
research has demonstrated that local
moisture is necessary to facilitate
granulation and re-epithelialization of the
ulcer [87]. If a wound is moist (wet-dry
dressing), the wound healing process will
be accelerated, and epithelialization will
be rapid [87]. According to the Wound
Healing Society (2006), the following
guidelines are recommended [87]:
Moist dressings are ideal to keep
the area moist and to control any
potential exudate.
After a debridement, the wound
should have a dry dressing to absorb
any bleeding for the first eight to 24
hours.
4. Nutrition.
Proper nourishment contributes to the support
and growth of granulation tissue [87], so
patients should be encouraged to eat a
well-balanced diet to maintain homeostasis.
However, patients who are at the highest risk
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Elite CME
of inadequate wound healing are typically
malnourished. Therefore, the nurse and health
care providers should encourage adequate
calories, protein and hydration based upon
the patient’s weight, nutritional goal and
laboratory data, which are calculated by the
consulting dietician [40].
ŠŠ For the average healthy adult, the
daily nutritional requirements are
approximately 1.25 to 1.5 grams of
protein per kilogram (kg) of body weight
and 30 to 35 calories per kg [78]. The
patient’s weight should be assessed
whenever there is a change in his or her
condition. If the patient is malnourished
or has a chronic illness, he or she will
be deficient in protein, which is found
in approximately 25 percent of all
hospitalized patients [78]. Examples
of foods high in protein include beef,
chicken, pork, turkey, eggs, liver, milk
and cheese [15].
All patients should be encouraged
to eat adequate servings of protein,
carbohydrates, vitamins, minerals
and trace elements to ensure wound
healing, especially with any pressure
ulcer [49].
ŠŠ If a patient is unable to consume
enough calories, protein or
nutrients with his/her food
intake, a physician should be
notified to prescribe a dietary
consult if not already ordered
to ensure the patient receives
the most appropriate nutritional
supplement.
ŠŠ In 2006, Medical Nutrition
USA Inc., (MDNU) announced
results of a clinical trial on its
Pro-Stat(R) modular protein
supplement and found that the
use of Pro-Stat(R) improved the
healing of pressure ulcers among
long-term care residents by 96
percent [58].
Patients who have vitamin or
mineral deficiencies should receive
supplemental treatment immediately
to promote the healing process [40,
78].
ŠŠ Vitamin A is a fat-soluble vitamin
that increases fibronectin on the
wound surface, thus increasing
cell chemotaxis, adhesions
and tissue repair. Vitamin A
is necessary to maintain the
integrity and function of the skin.
It is found in milk, eggs, cheese,
fish, dark green vegetables,
oranges and fresh fruits.
ŠŠ Vitamin C is a water-soluble
vitamin that promotes collagen
synthesis and serves in the
formation of connective tissue.
It’s found in citrus fruits,
strawberries, tomatoes, potatoes,
broccoli and cantaloupe.
ŠŠ Vitamin E is a fat-soluble
antioxidant that facilitates cell
membrane function. It is found in
vegetable oils, margarine, whole
grains and green leafy vegetables.
ŠŠ Zinc is a mineral that helps
maintain the structure and
function of the body and skin
while it collaborates with other
nutrients. It is in meat, fish,
seafood, liver, eggs and beans
[40].
5. Pain.
Depending upon the depth of injury and
other co-morbidities, patients may endure a
significant amount of pain during the dressing
change. Therefore, it is important to assess
the pain level according to the hospital policy
as a baseline prior to any treatments and
before/during/after administration of pain
medications. In addition to administering
pain medications, there are other treatment
modalities that may help reduce the pain level
[94]:
ŠŠ Cover the wound appropriately.
ŠŠ Adjust support surfaces for the patient.
ŠŠ Reposition the patient.
6. Sutures.
If sutures are required, typically the wound is
open or longer than half an inch. The patient
should seek care within six hours of the
injury to avoid infection and to ensure sutures
can be implemented [54].
7. Tetanus vaccination.
The CDC recommends that if a patient
presents with any wound other than a clean,
minor wound and does not have a clear
history of at least three tetanus vaccinations,
he or she should receive the tetanus immune
globulin (TIG) and a tetanus vaccination [21].
The tetanus immune globulin takes effect
immediately, whereas a vaccination takes up
to four weeks to be effective (See Table 5, at
the end of this chapter).
Tetanus is caused by the neurotoxin
etanospasmin (clostridium tetani), a spore
of the tetani organism that is found in soil
[56]. The complication of tetani organisms
interfering with the neurotransmitters is
stiffness in the jaw and neck muscles,
followed by uncontrolled spasms,
exaggerated reflexes and painful convulsions
[56]. Tetanus is most prevalent in the elderly,
especially older women (greater than 55
years of age), migrant workers, newborns,
injection drug users, diabetics and those with
nonacute wounds (chronic ulcers, gangrene,
abscesses/cellulitis) [21, 56]. The CDC has
released the following statistics [21]:
ŠŠ Elderly – In 2004, 71 percent of the 34
cases reported were among persons more
than 40 years of age, and 47 percent were
among persons greater than 60 years of
age.
ŠŠ Older women – Research has
demonstrated that women 55 years of age
Elite CME and older do not have protective levels of
tetanus antibody.
ŠŠ Diabetics – The CDC has reported
that tetanus is about three times more
common in diabetics, and fatalities are
about four times more common.
ŠŠ Nonacute wounds – Chronic ulcers,
gangrene, abscess and cellulitis account
for one in six cases of reported tetanus;
one in 12 reported cases had no reported
injury or lesion.
8. Tissue perfusion/oxygenation. It is
imperative to ensure that there is adequate
oxygenation within the body as it is a
foundation for wound healing. Therefore,
depending upon the mechanism in which the
wound was inflicted, it is important to first
address the adequacy of airway, breathing
and circulation (ABC) before initiating any
other treatment modalities. If the patient has
any symptoms of shock due to extensive
blood loss, the shock needs to be treated
immediately. Signs and symptoms of shock
include [50]:
ŠŠ Pale, mottled, diaphoretic skin.
ŠŠ Tachycardia.
ŠŠ Tachypnea.
ŠŠ Hypotension (this is typically a late sign
of shock).
Once the shock has been stabilized and/or
ruled out, there are other general factors that
contribute to the body’s inability to maintain
adequate tissue perfusion and oxygenation
[87]:
ŠŠ Dehydration because it increases
sympathetic tone such as cold, stress
or pain, which will decrease tissue
perfusion.
ŠŠ Cigarette smoking decreases tissue
oxygen by peripheral vasoconstriction.
ŠŠ Hypovolemia will reduce the amount of
circulating oxygenated blood, which may
cause further problems for the patient.
Therefore, if the patient is bleeding,
it is important to stop the bleeding
immediately. A small amount of bleeding
may be cleansing to the wound and will
stop within minutes [54]. However, with
a patient who presents with a gushing,
oozing gunshot or stabbing wound
perfusing large amounts of blood, the
following steps should be implemented to
control the bleeding [54]:
Apply firm pressure above the level
of the heart with a gentle cloth.
If the blood continues to soak, apply
additional cloths on top of that
cloth directly over the wound with
pressure.
In 2004, the Food and Drug Administration
(FDA) approved a new solution to halt
bleeding, QuikClot [35]. QuikClot is made
from a zeolite material that occurs naturally
in volcanic rock and is poured directly into a
wound that will not stop bleeding [35].
Page 15
9. Wound cleaning.
It is imperative to cleanse wounds
appropriately to remove foreign or necrotic
matter, reduce odor and bacteria [15].
According to the Wound publication,
numerous research studies were implemented
to evaluate the effectiveness of woundcleansing products 15]:
According to 11 randomized studies
found on Medline, EM BASE, CINAHL,
and Cochrane databases, there is no
evidence that saline wound cleansing is
more effective than tap water in reducing
wound infection or improving healing.
In order to ensure proper wound cleaning,
there are certain measures that need to be
implemented for adequate healing.
Cleaning.
The ideal method of irrigating all traumatic
wounds is to attach a syringe and a 22-gauge
angiocatheter to one liter of normal saline
with IV tubing [19]. It is important to
maintain pressure of 5 to 15 pounds per
square inch to ensure effective cleaning [19].
In the latest 2008 research, a piston or bulb
syringe is not recommended for irrigation
because it does not generate the necessary
pressure required to clean the wound
efficiently [19].
Skin cleansers [23].
ŠŠ The skin around the wound contaminates
should be cleansed with a skin cleanser to
neutralize the drainage and to eliminate
any odor.
ŠŠ Anytime a wound is cleaned, it needs to
be pat dried and not rubbed to prevent
further skin breakdown.
Moisturizers (emollients) are utilized for
dry skin. It should be noted that dry skin
is not attributed to the abnormal function
of water intake, but to abnormal function
of the epidermis [56]. According to the
CMDT 2008, the best moisturizers include
petroleum, mineral oil, Aquaphor and Eucerin
[56]. The best way to apply a moisturizer is
to apply it to wet skin in a thin layer with
the grain of the hairs, rather than rubbing
it up and down in order to avoid folliculitis
(inflammation of hair follicles) [56].
ŠŠ Moisturizers should be implemented to
provide hydration, soften and to protect
the skin from breakdown.
ŠŠ The Cleveland Clinic recommends using
creams instead of lotions because they
have less water, and research has shown
that they provide intensive hydration for
severely dry skin for 24 hours.
Apply the moisturizing cream to all
skin surfaces.
Apply the moisturizing cream
immediately after bathing while the
pores are still open from the water.
10.Other treatment options for chronic
wounds.
Depending upon the severity and depth of
the chronic wounds, such as pressure ulcers,
diabetic foot ulcers and leg ulcers, there are
other adjunctive therapies that are used in
collaboration with the standard treatment
modalities to promote wound healing and to
prevent complications.
ŠŠ Electrotherapy.
Due to the prevalence of disvascular
amputations and the costs associated
with them, electrotherapy has been an
effective adjunctive therapy for ischemic,
chronic wounds [36]. Electrotherapy
is intended to supplement surgical
revascularization, which is the standard
care for ischemic wounds. However,
when vascular bypass is associated with
minor amputation, such as with digits or
at the trans-metatarsal level, necrosis may
still occur along the suture line, even with
distal pulses present. Distal necrosis is
more challenging to treat when a patient
is a poor surgical candidate because of
failing health or limited outflow arteries
[36].
ŠŠ Grafts, skin substitutes or flap closures.
There are times when chronic wounds
have soft tissue visible but are not healing
well. At that time the physician may
contemplate a skin graft, application of
bioengineered skin substitutes or flap
closures [77]:
Dermagrafts are a cryopreserved
human fibroblast-derived dermal
substitute produced by seeding
neonatal foreskin fibroblasts onto
a bioabsorbable polyglactin mesh
scaffold. Dermagraft is useful for
managing full-thickness chronic
diabetic foot ulcers. It is not
appropriate for infected ulcers, those
that involve bone or tendon, or those
that have sinus tracts. A multicenter
study of 314 patients demonstrated
significantly improved 12-week
healing rates with Dermagraft (30
percent) versus controls (17 percent).
ŠŠ Apligraf (Organogenesis) is a
living, bi-layered human skin
substitute. It is not appropriate for
infected ulcers, those that involve
tendon or bone, or those that have
sinus tracts.
ŠŠ Bioengineered skin substitutes
have been questioned because the
mechanism of action is not clear,
the efficacy is questionable, and
the cost is high.
ŠŠ Hyperbaric therapy.
Hyperbaric therapy involves placing
the patient into a large chamber that
promotes wound healing; it supports
bacterial destruction by white blood
cells, collagen growth via fibroblast
proliferation, and assists in the
development of new epithelial tissue [11].
ŠŠ Maggot debridement.
Maggot debridement therapy (MDT)
is an ancient wound-care modality that
has been around since the battle of St.
Quentin in the 1500s [45]. However,
MDT was not utilized in the United
States until the 1930s, and then it
lost popularity when antibiotics were
introduced in the 1960s [45]. However,
the effectiveness of MDT was not
researched until 1989 in Long Beach,
Calif. [93]. In 2004, the FDA approved
production and marketing of maggots as
a medical device under the brand name of
Medical Maggots [45, 93].
MDT uses fly larvae, or immature flies
that are hatched from eggs. Surprisingly,
not all maggots are capable of feeding
in necrotic, gangrenous tissue. The flies
used most often in therapy are “blow
flies” (calliphoridae); and the species
used most commonly is phaenicia
sericata, the green blowfly [93]. The
Wound Care Network lists the following
advantages and disadvantages of MDT
[93]:
It takes approximately 15-30 minutes
to apply a secure dressing to keep the
maggots in place, with an excellent
safety record.
Medicinal maggots have three
actions. They:
ŠŠ Debride the wound by dissolving
the dead (necrotic), infected
tissue.
ŠŠ Disinfect the wound by killing
bacteria.
ŠŠ Stimulate wound healing.
Maggots are highly perishable and
should be used within 24 hours of
arrival.
This treatment is simple enough that
it can provide thorough debridement
when surgery is not available or is
not the optimal choice.
Low cost of treatment.
Clinical studies indicate that MDT
accomplishes the same goal as other
treatments in a shorter, cost-effective
manner [45].
Dressing – In order to keep the maggots
isolated to the necrotic wound area, a
porous, meshlike covering (i.e., nylon
netting) should be placed over the wound
border, then secured with tape, glue or a
hydrocolloid pad. Remove the dressing
and maggots 48 to 72 hours after the
initiation of treatment [93].
Treatments – The size of the wound and
the goal of treatment will determine the
necessary required treatment cycles of
maggots. Typically the average patient
receives two to four cycles [93].
ŠŠ Negative pressure wound therapy
(NPWT).
Vacuum-assisted closure (VAC) was
cleared for use by the FDA in 1995.
It is used to reduce colonization of
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Elite CME
bacteria and increase wound healing
by [37]:
ŠŠ Removing fluid from the
extravascular space.
ŠŠ Lowering capillary after-load.
ŠŠ Improving blood supply during
the inflammatory phase.
ŠŠ Increasing the peripheral blood
flow.
VAC therapy was originally
developed as an adjunct for pressure
ulcers. However, in 2006, it gained
approval for the treatment of other
complex, chronic wounds, such as
diabetic foot ulcers, flaps, grafts,
traumatic wounds, dehisced wounds,
in preparing wounds for closure and
mainstay treatment of stage three
and four pressure ulcers [84]. The
suction in the VAC attaches to the
wound edges toward the wound
center to improve local oxygenation
and prompts angiogenesis to deliver
negative pressure ranging from 50 to
200 mm Hg [37] (See Table 6, at the
end of this chapter).
ŠŠ Surgery.
Surgery is applicable if the wound is
not healing after treatment or if the
wound has failed to produce granulated
tissue [8]. The most common surgeries
completed to promote the growth of new
tissue include [32]:
Free tissue transfer flap, which
involves moving tissue from one side
of the body to another area.
Myofasciocutaneous flap or rotation.
Random flap.
Specific treatment of wounds
In order to properly treat each wound, it is
important to adhere to the generalized care of
wounds considering tissue perfusion, nutrition,
pain, wound cleaning, dressing changes and
the potential need for sutures or surgery. The
ultimate goal in treating all acute wounds, such
as abrasions, lacerations, bites, puncture and/or
surgical wounds is to control the hemorrhage,
protect the patient and the wound, and to provide
comfort [19]. Treating chronic wounds is a little
more complex as it requires specific interventions
based upon other co-morbidities of the patient. In
addition, various research studies and guidelines
provide the following specific treatment
modalities for each type of wound.
1. Treatment of abrasions and scrapes.
Typically, abrasions and scrapes do not
require extensive treatment because they
are only a superficial break in the skin. The
primary treatment for abrasions and scrapes
is [30]:
ŠŠ Bleeding – If there is any bleeding, stop
it with firm pressure above the level of
the heart for approximately 10 minutes.
If debridement is required, remove any
residual foreign material with forceps
and/or pulsatile lavage with suction [4].
Cleaning – Wash the abrasion and/
or scrape four times a day for the first
48 hours, then keep the area covered
with a sterile bandage. The AACW
recommends cleaning the skin with
NS or a noncytotoxic wound cleanser
[4]. Cytotoxic products to avoid
include all of the following [4]:
ŠŠ Hydrogen peroxide.
ŠŠ Iodine solutions.
ŠŠ Merthiolate, Mercurochrome.
It is important to ensure that all of
the dirt and debris is removed from
the abrasion and/or scrape. If the
abrasion or scrape is due to a bite
and/or a combination of a puncture or
deeper wound, do not scrub the deep
wound or bite; it is recommended that
the area be just washed out.
Dressing – Once the area has been
cleaned and the bleeding has stopped,
protect the injury with a nonadherent
dressing to promote a moist
environment for optimal healing [4].
2. Treatment of animal or human bites.
Antimicrobials. Due to the prevalence and
severe risk of infection, antibiotics are
administered prophylactically and with
any known infection depending upon the
identified source. Most wounds do not
develop signs and symptoms of infection
until 24 to 72 hours after the bite [19].
Infections are caused by aerobes and
anaerobes or anaerobes alone (36 percent)
[56]:
ŠŠ Aerobic.
Pasteruella multicida, the most
common isolate (75 percent of cat
bites and 50 percent of dog bites)
is a gram negative coccobaccillus
that is usually resistant to the
penicillinase-resistant penicillins, yet
it is sensitive to penicillin [6, 56].
However, research has demonstrated
that pasteruella multicoida is best
treated with a penicillin (PCN) or
a tetracycline [56]. Cephalosporins
administered orally do not reach
blood concentrations high enough to
eradicate the pasteurella multicoida
infections effectively [6].
Staphylococcus aureus, another
common aerobic bacteria, occurs in
30 percent of bites that are usually
resistant to PCN, which may pose a
potential problem for the efficacy of
treatment [6].
ŠŠ Anaerobic.
Fusobacterium.
Bacteriodes.
Porphyromonas.
Prevotella.
Empiric antibiotic therapy is most effective
with Amoxicillin-clavulanic acid 500 to 800
milligrams by mouth twice a day or Cefoxitin
500 milligrams IV twice a day for seven to
fourteen days [19]. However, if the wound
involves the bone and/or joints, antibiotic
Elite CME therapy should be prescribed for 21 days
[19]. If a patient is allergic to PCN, then
Doxycycline 100 milligrams by mouth twice
a day or the combination of Clindamycin
with Bactrim or Ciprofloxacin should be
prescribed [19].
According to the CMDT (2008) guidelines,
the antibiotic treatment recommendations for
bites are as follows [56]:
ŠŠ High-risk bites – Typically in all high
risk-bites, the patient will be treated
prophylactically, such as a cat bite (30 to
50 percent risk). Therefore, the patient
will be administered dicloxacillin 0.5
grams orally four times a day for three
to five days. Dicloxacillin is a narrow
spectrum beta-lactam antibiotic in the
PCN family and is used to treat infections
caused by susceptible gram-positive
bacteria, such as staphylococcus aureaus,
another common bacteria found in bites
[25].
ŠŠ Hand bites – If a patient presents with a
bite to the hand, regardless of whether it
is inflicted by an animal or a human, the
patient will be administered PCN V 0.5
grams orally four times a day for three to
five days [57].
ŠŠ Known bacteria – If the wound has a
known bacterial infection, the appropriate
antibiotic will be administered based
upon the type of bacteria, co-morbidities,
risk factors and any allergies. The
response to treatment may be slow and
should be continued for at least two to
three weeks.
ŠŠ Human bites – Typically human bites are
prescribed intravenous (IV) therapy with
a B-lactam plus B-lactamase inhibitor
combination (such as Unasyn, Timentin,
Zosyn) and/or a second-generation
cephalosporin (cefoxitin, cefotetan,
cefmetazole). If there is a PCN allergy,
clindamycin plus a fluoroquinolone will
be prescribed. Because of the variability
of human bite wounds, a culture should
always be taken to identify the exact
bacteria source.
ŠŠ Pregnant women – Macrolides should
be prescribed if the patient is allergic to
B-lactamase PCNs [70].
It should be noted that dicloxacillin and PCN
have been studied in their treatment of bite
wounds. There has been concern about their
use due to their narrow spectrum of activity
(gram-positive bacteria), especially since the
most common bacteria is pasteruella (a gramnegative bacteria) [56]. The CMDT (2008)
has implied that other agents that have not
been studied for their efficacy of bite wounds
may be more beneficial, such as [56]:
ŠŠ Cefuroxime, a second-generation
cephalosporin, has broad spectrum
activity against anaerobes, gram-positive
and gram-negative bacteria [46]. The
typical adult dose is 0.25-0.5 grams
by mouth twice a day; in the pediatric
Page 17
patient, the dose is 0.125-0.25 grams
twice a day [46].
ŠŠ Amoxicillin-clavulanic acid (Augmentin)
is an extended spectrum PCN that has
greater activity with gram-negative
bacteria and has the ability to penetrate
the outer membrane. It is inactivated
by many of the B-lactamases [46].The
typical adult dose is 500/125 by mouth
three times a day to 875/125 by mouth
twice a day. In the pediatric patient, the
dose is 20 to 40 milligrams per kilogram
by mouth three times a day [46].
ŠŠ Clindamycin plus a fluoroquinolone
(ciprofloaxin or Levofloaxcin).
Clindamycin is a chlorine-substitute
that has coverage against anerobic
and streptococci, staphylocci and
pneumococcal [46]. The typical adult
dose is 0.15-0.3grams every eight hours.
The pediatric dose is 10 to 20 milligrams
per kilogram a day [46].
Cleaning – The most important component
of treating an animal bite is wound cleaning
and irrigation [13]. Because of the vast array
of bacterial sources in a bite, it is imperative
to irrigate the wound immediately to decrease
the number of potential bacteria that may
have been inoculated during the bite [6,
19]. The American Veterinary Medical
Association (AVMA) recommends that
all animal bites should be cleaned in the
following way [6]:
ŠŠ First, clean the wound with povidoneiodine solution.
ŠŠ Second, irrigate the wound with normal
saline (NS) 0.9 percent using an 18-gauge
blunted needle on a 35 milliliter (ml)
syringe. A liter of NS may be used at a
pressure of 50 to 70 psi.
If rabies is speculated, the wound needs to
be cleaned immediately with soap and water
or a 1 percent povidone-iodine solution to
potentially lower the transmission rates [19].
Debridement – Depending upon the depth
of the injury and the surrounding skin, a
debridement may be required to remove
any devitalized tissue [27]. According to
the AVMA research, infection developed
in approximately 17 percent of wounds
that were not debrided [6]. Other perks of
debridement include easier surgical repair
and a smaller scar at the site of the injury [6].
Sutures – Over the years there has been
controversy regarding suturing an animal
wound. For many years, suturing was
absolutely omitted in treatment guidelines
because of reports that it can result in a loss
of function of the area when bacteria are
trapped under the sutures [57]. However,
newer thought by the AVMA, eMedicine
and the CMDT of 2008 implies sutures may
be used if the primary bite site has been
meticulously cleaned and irrigated [27]:
ŠŠ If the wound is capable of closing on
its own; such as a fresh dog bite and a
facial bite (if it does not require cosmetic
surgery) [19].
ŠŠ Dependent upon the risk of infection in
the bite wound.
ŠŠ Dependent upon whether there are any
cosmetic considerations.
Hand wounds – If a bite wound is infected
or if the bite wound is on the hand, it should
never be sutured because of the risk for loss
of function, especially in the hand, because
it may be a closed-space infection [56].
Hand wounds should be wrapped in sterile
gauze, splinted in a position of slight wrist
extension, then continuously elevated [13].
In addition, it should be noted that cat bites
should never be sutured because of depth
of the wound and higher risk of bacterial
infection inside the wound [27].
minimal protective levels of 0.05
International Units (IU) per milliliter.
Post exposure prophylaxis for
previously unvaccinated patients
is 20 IU per kilogram as soon as
possible after exposure, with a total
of five intramuscular (IM) doses on
days 0, 3, 7, 14 and 28.
Previously immunized patients will
receive 1 milliter IM on day zero and
day three.
The rabies vaccine must be injected
IM and never subcutaneous (SC),
intradermal (ID), or intravenous (IV).
In adults, the nurse should inject the
vaccination into the deltoid muscle;
small children should receive the
vaccination into the anterolateral
zone of the thigh.
Vaccinations – Once the cleaning has been
Follow-up – The nurse should tell patients
completed, there are other prophylactic
with a bite wound to inform their primary
vaccinations and/or medications that may
care provider (PCP) immediately if they
need to be administered depending upon the
experience any signs and symptoms of
patient’s previous vaccination history and/or
infection or a change in sensation of the
risk factors.
area (numbness and/or tingling). In addition,
ŠŠ Tetanus toxoid is administered as
patients treated on an outpatient basis and
advised in CDC guidelines (See the
sent home after being seen in the ER should
previous generalized treatment of wounds
follow up with the PCP within 48 hours
for guidelines of administering the
to reduce the risk of treatment failure and
tetanus vaccination and Table 6 at the end
complications. Failure to identify and treat
of this chapter).
the bite appropriately and efficiently may
ŠŠ Hepatitis B is administered as a
result in complications such as cellulitis,
prophylaxis for patients who have been
tenosynovitis, septic arthritis, osteomyelitis,
bitten by known carriers of hepatitis B.
abscess and/or fatal sepsis [6]. In addition,
The patient will be given the hepatitis
cat bites may cause cat scratch fever, which
B immune globulin immediately at the
results in adenopathy and which is typically
time of injury because it will begin to
self-limiting [27].
work immediately; then the patient will
be placed on a regimen based on CDC
It is estimated that only 1 to 2 percent of
guidelines in 30 days [20].
all patients who present with a bite will be
ŠŠ Human immunodeficiency virus
hospitalized. A patient should be hospitalized
(HIV): Prophylaxis is not typically
if he or she is experiencing any systemic
recommended, because it is a potential
symptoms (fever, chills), severe cellulitis,
risk that is low [56].
suspected noncompliance or infected bites
ŠŠ Rabies shot (human diploid) is
[19].
administered depending upon the risk of
3. Treatment of bruising.
rabies exposure and the guidelines of the
The treatment of bruising is predominately
city or state public health departments,
superficial as it affects the epidermis of the
CDC and the Advisory Committee
skin. The initial treatment, according to the
on Immunization Practices [19, 27].
AACW, includes [4]:
If the patient has been exposed to
ŠŠ Apply cold compresses for 15 to 20
rabies, the local health department and
minutes per hour while awake for the first
public authorities need to be notified
48 hours.
immediately to decide whether the patient
ŠŠ After the first 48 hours, apply warm
should be isolated, observed and/or
compresses for comfort to the bruise.
quarantined [19]. The rabies vaccination
ŠŠ Avoid massaging the bruised area.
is an inactivated form of the virus grown
ŠŠ Avoid taking any NSAIDS or aspirin
in primary cultures of chicken fibroblasts
(ASA) products for pain relief.
and it offers active immunity if it is
4. Treatment of burns.
used in combination with the human
It is crucial to ensure the patient receives
rabies immune globulin and local wound
safe, expert care when dealing with a
treatment [27]. The vaccination provides
burn. It is important that the patient is
protection to a patient’s post-exposure
seen immediately to prevent long-term
of a bite in all of the age groups, and the
complications (such as cardiorespiratory
protocol is as follows [27]:
distress and compromise) with major wounds
Fourteen days after initiating the
and/or inflammation and infection that can
immunization series, anti-rabies
occur in any burn patient. The type of injury
antibody titers reach levels above
Page 18
Elite CME
will determine the primary skin treatment
related to the burn injury [5]:
ŠŠ Antibacterials – Because of the
complexity of bacteria, there is no ideal
antimicrobial to prescribe for each
scenario. Therefore, the most commonly
prescribed topical antimicrobials are
discussed, and they may be applied
with Bacitracin ointment. The ideal
antibacterials that are applied to the skin
should cover broad spectrum bacterias
and be nontoxic to the skin. The ideal
anti-bacterial agents are [50]:
Silver sulfadiazine (Silvadene, SSD)
(1 percent solution). Silvadene is the
most common agent utilized because
of its excellent ability to fight gramnegative and gram-positive bacteria.
It is rarely toxic.
Silvadene should be used with any
open treatment or with a light or
occlusive dressing.
ŠŠ A major side effect of Silvadene
is that it may induce transient
leukopenia, low white blood
cells (WBC). Therefore the nurse
should monitor the WBC as
ordered and notify the doctor if
the patient’s WBC is decreasing.
According to Lippincott,
Silvadene should be discontinued
if the WBC is lower than 1,500 in
adults or 2,000 in children. The
nurse can anticipate the WBC to
return to normal limits within two
to four days of discontinuation of
the product.
ŠŠ Avoid with any sulfa allergies
[19].
Mafenide acetate (Sulfamylon) (10
percent solution). Sulfamylon is
effective against most gram-positive
bacteria and gram-negative.
ŠŠ Sulfamylon cream should be
applied without dressing and reapplied every 12 hours.
ŠŠ If a dressing is required, apply a
bulky wet dressing and rewet it
every two to four hours.
ŠŠ The disadvantage of Sulfamylon
is it causes pain during and
immediately after the application.
Silver nitrate (0.5 percent solution).
Silver nitrate is a clear solution with
low toxicity risk and has effective
coverage against most common burn
pathogens.
ŠŠ Silver nitrate should be
applied with a bulky dressing
and rewet every two to four
hours to maintain therapeutic
concentration levels.
ŠŠ Cleaning – All burn wounds need to be
cleansed initially and then daily with a
mild antibacterial cleansing agent and
saline solution or water [19].
ŠŠ Debridement – If the burn has any
blisters or eschar, it needs to be removed
with natural, enzymatic, mechanical and/
or surgical debridement [50]:
Natural manner involves the body’s
own ability to have the eschar attempt
to separate from the underlying
vulnerable tissue in combination with
the nurse doing daily or twice daily
(BID) dressing changes. Depending
upon the hospital policy, forceps
or scissors may be encouraged to
attempt to remove the eschar.
Enzymatic agents are applied to
the wound and typically induce a
more rapid debridement process of
removing the eschar.
Mechanical or surgical debridement
involves removing nonviable tissue
to the viable base.
ŠŠ Dressings – Prior to any dressing
change and/or procedure, it is crucial
that the nurse assesses the patient’s pain
level frequently and avoid waiting for
complaints of pain to intervene. The
typical dressing is 4 x 4 gauze pads or
several layers of Kerlix bandages. All
dressing changes should be under sterile
technique. In addition, depending upon
the depth of injury, other dressing covers
may be more applicable to promote
wound healing [50]:
Minor burns need to be immersed
in cool water at a temperature of 55
degrees Fahrenheit or application of
cool compresses.
ŠŠ The American Burn Association
classifies a minor burn as one that
involves less than 15 percent of
total body surface area (TBSA)
for those 10 to 50 years of age, or
less than 10 percent of TBSA for
those over 50 years of age [19]:
The dressing should be a
thin layer of antimicrobial
cream or ointment, such as
Silvadene. If the patient has
a sulfa allergy, Bacitracin is a
great alternative.
ŠŠ Alternative dressings include
DuoDerm, OpSite, Epigard,
Epi-Lock, Biobrane or Tegaderm.
These biosynthetic dressings are
required to stay in place for one
to two weeks until the wound
heals.
ŠŠ The wound should be cleaned
and redressed twice a day for
seven to 10 days until the wound
is healed.
ŠŠ If the patient has a burned
extremity, it should be splinted
and elevated.
Major or severe burns – The
primary goals are to keep the
patient’s airway open, maintain
cardiac output, adequate hydration
and prevent infection.
Partial thickness burns require
Elite CME DuoDerm, Op-site, or Vigilon to
promote healing. A partial thickness
burn over 30 percent TBSA or a full
thickness burn over 5 percent TBSA
needs to be covered with a clean, dry,
sterile bed sheet to preserve the body
temperature and to protect the skin.
ŠŠ The DuoDerm covers the partial
thickness burn and it prevents
bacterial contamination.
ŠŠ The Op-site covers clean
partial thickness burns and/ or
clean donor sites. Op-site also
provides a moist environment for
epithelization to occur.
ŠŠ Vigilon is a suspension on a
polymethylene mesh support
that helps clean small partial
thickness burns.
Post surgical – After a surgical
procedure, the patient should have
a wet-to-dry dressing change every
four to six hours as ordered. Due to
the frequency of the dressing change,
provide warm blankets to the patient
to prevent heat loss. In addition, a dry
top layer of stockinette or a cotton
bath blanket prevents evaporative
heat loss.
Other treatment modalities – There
are other treatment modalities with
burns, depending upon the severity of
the burn, the patient’s health history
and/or access to health care, such as:
ŠŠ Hydrotherapy – It involves
the patient being immersed into
a body of water to facilitate
cleansing and debridement of
the burned area [50]. The unique
advantages of implementing
hydrotherapy in the treatment
plan are [50]:
Topical medications, adherent
dressings and eschar are
more easily removed during
the immersion in the water,
which causes less pain to the
patient.
It encourages the patient to
implement range of motion
exercises (ROM) in the
immersion of water to build
up strength to the affected
area.
However, as with any treatment,
there may be disadvantages [50]:
The patient loses body heat
and sodium each time he or
she is immersed in the water.
Therefore, it is recommended
that if hydrotherapy is
implemented, the time in the
immersion of water should
be limited to decrease the
loss of body temperature and
subsequent chilling.
The immersion of water all
over the body may induce
Page 19
generalized pain to the
patient.
The patient may experience
more anxiety before the
hydrotherapy treatment.
Pain – Minor burns are very painful,
and the nurse should always make
sure that prophylactic analgesics
are provided to the patient before
any dressing change and as needed.
The most beneficial pain medication
to administer is ibuprofen, an
anti-prostaglandin that has a good
anti-inflammatory and analgesic
component [19]. Codeine may be
another option.
Vaccinations – Tetanus prophylaxis
if needed.
5. Treatment of lacerations or cuts.
The goal of treating lacerations includes
prompt healing, minimizing the risk
of infection and limiting cosmetic
disfigurements [13]. The first mode of
treatment is to ensure there are no other
serious injuries present when a patient
presents with a laceration [13]. Once other
injuries have been ruled out, the bleeding
should be controlled with direct pressure and
elevation (if possible) [13]. Clamping should
be avoided as it may damage adjacent nerves
[13]. Based upon the Merck guidelines of
2006, the lacerated wound should be treated
this way [13]:
ŠŠ Cleansing – Clean with NS and/or
antibacterial soap with water and avoid
any harsh chemicals, (such as povodine
iodine or hydrogen peroxide) or products
(brushes or rough materials) because
the subdermal tissue of the wound is
delicate. The lacerated wound may also
be cleansed with an irrigation system
using NS in a 20 to 35 milliliters syringe
with a 20-gauge needle or an IV catheter.
Povodine-iodine may be used around the
injury, but not in the wound to reduce
skin flora.
ŠŠ Debridement – All devitalized tissue
should be removed to ensure adequate
granulated tissue healing.
ŠŠ Closure – Individual patient care should
be considered before deciding whether
a wound should be closed based upon
age, cause of the laceration, the degree
of contamination and the patient’s risk
factors. However, a cat bite laceration
should never be closed, nor should a bite
to the hand, a puncture wound or a highvelocity missile wound.
Primary closure. The majority of
practitioners will close wounds on the
face or scalp immediately if they are
less than six to eight hours old.
Delayed primary closure. Other
wounds can be closed after six
to eight hours if there is any
inflammation present.
Sutures, staples, adhesive strips and
ŠŠ
ŠŠ
ŠŠ
ŠŠ
liquid tissue adhesives may be used to
close the wound.
Dressings – Change the dressing daily
or if it becomes wet or soiled. In addition
to the specific guidelines provided,
additional measures may be implemented
per the AACW dependent upon the depth
and/or specific type of laceration [53]:
Superficial lacerations. The goal of
dressing superficial lacerations is to
bring the wound edges together by
securing it with a butterfly/skin tape,
then applying a clean, nonadherent
dressing.
Deeper lacerations. In order for the
wound to heal appropriately, sutures
are typically required.
Lacerations on the face require a
plastic surgeon referral for potential
cosmetic surgery.
Tetanus – Administer the vaccination, if
necessary, according to CDC guidelines.
Medications – Antibiotics are not
required, but there is no harm and it may
be beneficial. If a wound infection occurs
or if the patient is at risk of developing
an infection, systemic antibiotics will
be prescribed. The drug of choice that is
effective against skin flora is cephalexin
500 milligrams twice a day or PCN 500
milligrams four times a day [53].
Other measures included in the
treatment of lacerations include the
following [53]:
Avoid excessive movement of the
affected area because it affects the
healing process.
Keep the wound clean and dry.
Follow up with the PCP 48 hours
after the injury occurred.
After 48 hours, the wound can be
cleaned with water or half-strength
hydrogen peroxide.
6. Treatment of perineal skin breakdown.
According to the Ostomy Wound
Management (OWM), the ultimate goal of
perineal skin care is to properly manage the
underlying incontinence through behavioral,
pharmacological and/or surgical interventions
[66]. Failure to manage the incontinence
will precipitate further skin breakdown or
complications. It is imperative that the wound
be properly cleaned utilizing appropriate
techniques and products, such as skin
cleansers and moisturizers as needed [23, 66]:
ŠŠ Perineal skin cleaners neutralize the
drainage and eliminate any potential
odors due to the incontinence. The OWM
recommends that after each incontinent
episode, the perineal area should be
properly cleansed with a product specific
for perineal skin cleansing. Ideal products
should include any of the following
humectin ingredients:
Glycerin.
Methyl glucose.
Esters.
Lanolin.
Mineral oil.
When a wound is cleansed, it needs to
be pat-dried and not rubbed to prevent
further skin breakdown [23].
Avoid no-rinse perineal cleansers, bar
soaps, products specific for routine
skin cleaning only or antibacterial
hand washing as it can dry the skin,
raise the pH and further erode the
epidermis layer of skin.
ŠŠ Moisturizers protect and soften the skin.
Perineal skin barriers, also referred to as
moisturizers or skin protectants, protect
the skin from exposure to irritants or
moisture and hydrate, soften and protect
the skin against breakdown [23]. The
active ingredients in moisturizers include:
Petrolatum.
Dimethicone.
Lanolin.
Zinc oxide.
There are two types of moisturizers,
a basic moisturizer and a moisturizer
barrier ointment [23].
ŠŠ Basic moisturizers – Basic moisturizers
should be used to provide hydration,
soften and to protect the skin against
breakdown. The Cleveland Clinic
recommends using creams over lotions
because they have less water, and
research has shown that they provide
intensive hydration for severely dry skin
for 24 hours.
Apply the moisturizer cream to all
skin surfaces.
Apply the moisturizer cream
immediately after bathing while the
pores are still open from the water.
ŠŠ Moisturizer barrier ointment – The
moisturizer barrier ointment protects the
skin from urine or stool if the patient
is incontinent of either function. The
main ingredients in moisturizer barrier
ointments are dimethicone, zinc or
petrolatum. Always clean the skin gently
and thoroughly, then apply a layer of the
product.
In addition, there are instances when the
moisturizer may be incorporated into the skin
cleanser or it may be formulated separately
as a cream (water based), ointment (oil based
preparation) or paste. Ointment (oil based)
products last longer on the skin. There are
also liquid barrier films that are available
that contain a polymer combined with a
solvent. Ideally, the solvent evaporates and
the polymer dries it to form a barrier for skin
protection. It is important to avoid any liquid
film barriers with barrier creams or pastes
because of the incompatibility of the products
[66].
The OWM also recommends that nurses
incorporate the use of perineal devices, such
as [66]:
Page 20
Elite CME
ŠŠ Underpads and/or absorbent pads may
be used if they keep the moisture away,
rather than trapping it in.
ŠŠ External catheters are used to collect
urine or a fecal incontinent collector
to collect feces. If the external urinary
Foley catheter and feces collectors are
used appropriately, they can prevent and
treat perineal skin breakdown. Rectal
tubes should be avoided because they can
perforate the bowel and damage the anal
sphincter.
7. Treatment of pressure ulcers.
The ultimate goal of treatment is to remove
any necrotic debris and to maintain a moist
wound bed that will promote healing and
the formation of granulated tissue [56].
All pressure ulcers should be treated in the
following manner per the recommended
Wound Care Information Network (WCIN)
guidelines [94]:
ŠŠ Enhance soft tissue viability and
promote healing of the ulcer in the
following steps [16]:
Ensure proper positioning – It is
speculated and believed that pressure
ulcers result from the compression of
soft tissue against bony prominences
[87]. Therefore, it is important to
ensure that the patient who is at risk
of a pressure ulcer or who already
has been affected by one should be
on a stringent repositioning schedule
to avoid further damage and/or
complications [87]. At this time, the
rule of thumb is to ensure that the
patient is turned at a minimum of
every two hours. However, it should
be noted that skin breakdown and
injury can occur in less time, so
repositioning should be customized
to the patient [41].
ŠŠ Keep the head of bed at the
lowest degree depending on the
patient’s medical conditions,
because levitation of the head
produces shear and friction
between the skin and the bed
surface [87]. Keeping the head
at the lowest position poses a
challenge for certain patients,
such as those in respiratory or
cardiac distress or who have a
feeding tubes. Therefore, the
guidelines recommend that if
possible, elevation of the head
should be limited to certain
increments [87]. During the time
frame that the head of the bed
needs to be at 90 degrees, the
nurse can tilt the head forward
more than 90 degrees with
pillows to keep pressure off the
sacral/coccyx area [41].
Ensure appropriate mattresses
and/or devices – Any patient who
is at risk or who has an ulcer on
admission should be ordered a
pressure-reducing surface mattress. In
order to alleviate pressure, consider
the amount of pressure required to
occlude the capillary blood flow,
also known as the capillary closing
pressure [41]. The normal capillary
closing pressure ranges from 12
to 32 mm Hg. Therefore, any
pressure device needs to be below
the capillary closing pressure to
prevent tissue ischemia [41]. Nurses
can monitor this by observing skin
color, the integrity of the skin and
temperature to assess capillary
flow adequacy because the device’s
reading may not be customized or
accurate for each particular patient
[41]. Research has demonstrated that
pressure-reducing devices can reduce
the risk of developing any ulcers
by 60 percent compared to standard
hospital beds [87].
ŠŠ If a patient has a stage 3 or 4
ulcer, he or she should be on an
air mattress, although they may
limit the ability of certain patients
to reposition themselves [87].
Therefore, nurses and nursing
assistants need to be attuned to
this potential problem. They need
to ensure the patient is turned
frequently and that the call light
is within reach of the patient.
ŠŠ Use devices such as pillows or
foam to keep heels off the bed
and to keep knees and ankles
from touching.
ŠŠ Do not position the patient on the
pressure ulcer.
ŠŠ Avoid ring cushions (donuttype) devices and seat cushions
that have the “bottom out”
appearance. They increase
venous congestion and edema
[87].
ŠŠ If the patient has an ulcer in the
area, sitting should be avoided
or limited to less than an hour
to avoid exacerbating the
wound [87]. If possible, nurses
should educate the patient and
the families to have the patient
shift his or her weight every 15
minutes while sitting to also
avoid the risk of exacerbating the
pressure ulcer [87].
ŠŠ Care of the ulcer.
Cleaning the wound – In order
to properly clean a pressure ulcer,
normal saline (NS) should be
utilized. Do not use povodine iodine,
iodophor, sodium hypochlorite
solution, hydrogen peroxide, Dakin’s
(sodium hypochlorite solution) or
acetic acid because they have been
shown to be cytotoxic. NS is safe,
and it is the preferred method [71].
Elite CME ŠŠ Deep wounds – If a patient
has a deep wound that requires
wound cleaning and/or irrigation,
research has demonstrated
that the nurse should use a
35-milliliter syringe [71]. In
addition, the irrigation should be
injected at a pressure of 4 to 15
pounds per square inch [71].
ŠŠ Eschar – Notify the doctor
immediately for removal. A
pressure ulcer cannot heal
appropriately if eschar is
present because it prevents new
granulation in the wound bed and
it is an ideal source of bacterial
growth [71].
Dressings – The ideal dressing
should protect the wound, be
biocompatible and provide ideal
hydration. According to the CMDT
(2008), the recommended guidelines
for treating specific pressure ulcers
are [56]:
Pressure ulcer stages:
Stage 1.
ŠŠ Polyurethane film.
ŠŠ Hydrocolloid wafer.
ŠŠ Semipermeable foam.
Stage 2.
ŠŠ Hydrocolloid wafer.
ŠŠ Semipermeable foam dressing.
ŠŠ Polyurethane film.
Stage 3 and Stage 4.
ŠŠ Exudate – If there is an
abundance of exudate, use a
calcium alginate dressing or
gauze packing as both have
excellent absorptive capabilities.
ŠŠ Shallow and clean – Use
a hydrocolloid wafer,
semipermeable foam or a
polyurethane.
Location – Certain locations, such
as the ear, make it challenging and
tedious for the nurse to apply a
dressing properly and efficiently.
ŠŠ Ear – Apply a thin hydrocolloid
dressing, approximately 5x7
centimeters to the wound.
Cut the strip, fold it in half
lengthways and then cut a
fringe along one edge. The
cuts should be approximately
0.5 centimeters apart.
Apply the uncut edges of
the dressing first and then
use the cut edges to fold
around the edge of the ear for
stabilization.
If there is any wound
exudate, a small piece of
alginate dressing should
be applied underneath the
hydrocolloid strip.
Debridement – Necrotic tissue is
laden with bacteria. Devitalized tissue
Page 21
impairs the ability to fight infection.
If the pressure ulcer wound has any
eschar or if the wound is a stage 3
or 4, it requires debridement, wound
cleansing, dressing application and
possible adjunctive therapy to ensure
wound healing [87].
Other treatment modalities – There
are other measures that the nurse
should implement to prevent further
progression of the pressure ulcer
and to facilitate the healing process,
including [71]:
ŠŠ Avoid the use of incontinent
pads or briefs with plastic liners
because the plastic holds the
moisture next to the skin and
promotes the production of heat
next to the skin.
ŠŠ Avoid massaging over bony
prominences to reduce the risk of
ulcer formation from excessive
friction.
ŠŠ Treating and managing bacterial
colonization and infection within
the pressure ulcer [16] – Research
has demonstrated that the majority
of ulcers within stages 2 through 4
are colonized with bacteria. It is also
important to prevent and treat any other
potential forms of bacteria that may be
colonized due to other sources, such as,
but not limited to the following: Foley
catheters (F/C), urinary tract infections
(UTI), sinus and respiratory infections
[87]. Research has demonstrated that a
bacterium that enters the blood stream
or lymphatic system can lodge into
compressed tissue, denervated tissue,
edematous tissue and/or any established
wounds, thus further exacerbating
multiple forms of bacteria in the body
[87].
If there is any speculation of a
bacterial infection within the
debrided ulcer or if the epithelization
phase is not progressing within two
weeks, then it should be biopsied.
Any ulcers that have more than 1 x
106 CFU/grams of bacteria following
a debridement should be treated with
topical antibiotics because research
has demonstrated that systemic
antibiotics are no longer effective
to decrease bacterial levels in
granulating wounds [87].
Early lesions should be treated
with topical antibiotic powders
and adhesive absorbent bandage
(Gelfoam). Once clean, they can be
treated with a hydrocolloid dressing
such as a DuoDerm. Established
lesions require surgical debridement,
cleaning and dressings [57].
8. Treatment of punctures.
The treatment regimen for punctures is
similar to the general recommendations for
abrasions and lacerations. It is important
to first stop any bleeding, then to clean the
wound and apply an antibiotic ointment such
as Neosporin or Polysporin.
9. Treatment of skin tears.
Due to the delicate nature of the skin, it is
imperative that nurses care for skin tears
gently and professionally. According to the
AACW, the following guidelines should be
implemented when caring for a skin tear [4]:
ŠŠ Cleaning – Clean with NS and pat dry
or leave to air dry. The skin should be as
closely approximated as possible [19].
If there is a skin flap present on, over or
around the skin tear:
Cleanse the area gently with NS.
Unroll the skin flap and approximate
the edges with butterfly/skin tapes.
ŠŠ Dressing – Cover the skin tear with one
of the following nonadherent dressings
[19].
Transparent left in place for five to
seven days.
Hydrogel.
Impregnated gauze (Xeroform).
Ensure that the skin tear is secured with
a gauze wrap or a stockinette to prevent
the removal of additional frail skin
around the area during dressing changes
and avoid disturbing the wound unless
exudate lifts the dressing, then use an
absorptive dressing.
Steri-strips may be useful in holding
the wound edges together, especially
in a grades 2 or 3 [19].
10. Treatment of surgical wounds.
Depending upon the type of surgery, various
dressings may be applicable. However, one of
the main treatment modalities is to administer
antibiotics prophylactically to reduce the
incidence of surgical wound infections,
regardless of the type of procedure [90]. The
most common side effect is postoperative
wound infections, so antibiotics are
administered.
ŠŠ Antimicrobials – On average,
approximately 1 million patients develop
wound infections after surgery each year,
extending a hospital stay by one week
while increasing the cost. The American
Academy of Family Physicians has
classified the risk of infection dependent
upon the type of operative wound [90]:
Clean wound – An elective surgery
that is not deemed an emergency
surgery. The risk of postoperative
infection is less than 2 percent.
Clean-contaminated wound – An
urgent or emergency surgery. The risk
of a post-operative infection is less
than 10 percent.
Contaminated wound – A
nonpurulent inflammation in which
there is a gross spillage from the
gastrointestinal tract, a major break
in the sterile technique, a penetrating
trauma of less than four hours or a
chronic open wound that needs to be
grafted or covered. The risk of postoperative infection is approximately
20 percent.
Dirty wound – A purulent
inflammation that is typically the
result of an abscess or a penetrating
trauma greater than four hours old.
The risk of postoperative infection is
approximately 40 percent.
For over a decade, the American
Academy of Family Physicians has
recommended the following protocol for
administering antibiotics to reduce the
risk of wound infections [90]:
Administer the first dose of
antibiotics 30 minutes before the
procedure.
The particular antibiotic and/or
antibiotics chosen are dependent
upon the surgical site, the most
common organisms isolated in the
vicinity of the surgery and the cost of
the drug.
ŠŠ Staphylococcus is the most
common bacteria postoperatively. Therefore, the
most commonly administered
antibiotic is cefazolin (Ancef,
Kefazol). If a patient has an
allergy to cephalosporins,
vancomycin should be
administered at one gram
intravenously (IV). Vancomycin
should also be administered
over cefazolin in hospitals
with high rates of methicillinresistant staphylococcus aureus
or staphylococcus epidermis
infections [46].
ŠŠ With gastrointestinal surgeries,
gram-negative and anaerobic
bacteria are isolated, so
antibiotics that fight those
particular organisms are
administered. Cefazolin (Ancef)
is the most common antibiotic
administered, and it is the
drug of choice for head and
neck, gastroduodenal, biliary
tract, gynecologic and/or clean
procedures [46].
Also administer the antibiotic at one
to two half-lives of the drug during
the procedure:
ŠŠ Cefazolin (Ancef, Kefazol) has a
half-life of 1.8 hours.
ŠŠ Vancomycin has a half-life of
three to nine hours.
ŠŠ Aminoglycosides have a half-life
of two hours.
ŠŠ Metronidazole (Flagyl) has a
half-life of eight hours.
Postoperative administration is not
indicated or recommended.
ŠŠ Dressings – According to Nursing Times
(2003), the most commonly used surgical
Page 22
Elite CME
dressings are simple, low-adherent
dressings. The following guidelines
should be considered when physicians
and nurses are applying the correct
dressing after surgery [12]:
Consider the frequency of the
dressing change and whether the
patient is able to take a shower daily.
If the patient is able to shower, use a
shower-proof dressing.
Research has demonstrated that
dressings should only be changed if
there are signs of infection, because
the wound will heal better if the
dressing is left undisturbed.
If the patient has an open surgical
wound that is healing by secondary
intention, then the appropriate
dressing should be based upon the
size, depth and position of the wound.
11. Treatment of ulcers.
ŠŠ Diabetic foot ulcers – The diagnosis of
diabetic foot ulcers is made based upon
clinical appearance; if the patient exhibits
pus or at least two of the following
symptoms of infection [38]:
Redness.
Swelling or induration.
Pain or tenderness.
According to the research composed
in Wounds (2008), it has been almost
five years since there have been any
alterations or enhancements in the
treatment of diabetic foot ulcers [75]. In
2004, the Infectious Disease Society of
America (IDSA) developed guidelines
for the treatment of diabetic foot ulcers
still used [38]:
Antimicrobial – The most common
pathogen identified in diabetic foot
ulcers are aerobic gram-positive cocci
(staphylococcus aureus). However,
if the patient has a chronic diabetic
wound or other chronic wounds
or if they have recently received
antibiotics, they may be infected
with gram-negative rods. Failure to
treat diabetic foot ulcers adequately
and efficiently may lead to further
complications, such as osteomyelitis
or cellulitis. The severity of the
infection, the cause and the patient’s
co-morbidities should be considered
when choosing the appropriate
antibiotic.
ŠŠ Outpatient mild to moderate
cases – The most commonly
prescribed antibiotics are:
Ofloxacin (Floxin), piperacillintazobactam (Zosyn), levofloxacin
(Levaquin), clindamycin
(Cleocin) and linezolid (Zyvox).
ŠŠ Moderate to severe cases are
typically prescribed parenteral
therapy initially.
The most challenging aspect of treating
diabetic foot ulcers is the concern for
osteomyelitis because it increases the
risk of surgery, especially amputations;
impairs wound healing; and predisposes
the patient to further infection. (See
Wound complications for further
explanation of osteomyelitis).
Cleaning – The diabetic foot ulcer
should be cleaned daily with NS to
promote a moist environment.
Debridement – Once the ulcer is
debrided, it is important to reduce the
risk of infection, thus reducing the
risk of an amputation.
Dressings – The dressing should be
changed frequently, at least every
24 hours, and the ulcer should
be checked often for infection
because the patient may not be able
to recognize it due to peripheral
neuropathy. One of the biggest
clues to infection is prolonged
hyperglycemia.
ŠŠ Leg ulcers.
Factors that influence healing of leg
ulcers include the size of the ulcer, other
risk factors and co-morbidities, and the
patient’s willingness to comply with
treatment modalities. An estimated 65 to
70 percent of venous ulcers heal within
six months of initiating treatment [47].
Venous – If the wound is related to
venous insufficiency, it should be
managed with strategies to control
the venous insufficiency, heal the
wound and prevent recurrence.
Cleaning – The first priority in
treating a venous ulcer is cleaning
with saline or cleansers such as SafClens [46]. If there is eschar present,
the physician or practitioner may
utilize a small curette or scissors to
remove the yellow fibrin eschar under
local anesthesia [56].
Compression stockings – The
majority of patients with venous
leg ulcers benefit from utilization
of compression bandages at the
level appropriate to their vascular
status. If the ulcer is the result of
venous insufficiency, the external
compression of the ulcer should be
between 30 and 40 metric units of
mercury (mm) (Hg) at the ankle to
prevent capillary transudate [47].
However, the results of the ABI
determines the compression therapy
as follows [30]:
ŠŠ ABI above 1.2 may indicate
calcified arteries and should not
be compressed. Do not compress
until further vascular studies are
completed.
ŠŠ ABI between 0.8-1.2 – full
compression.
ŠŠ ABI between 0.6-0.8 – lower
(mild to moderate) compression.
ŠŠ ABI lower than 0.5 – do not
Elite CME initiate compression, refer to
vascular surgeon.
Arterial/ischemic – Arterial wounds
should avoid compression therapy
or debridement as it can result in
necrosis or amputation [85]. The
mainstay of treatment is surgery with
revascularization to restore the blood
supply to the compromised limbs.
In order to improve the blood flow,
other medical conditions need to be
controlled, such as hyperlipidemia,
hypertension and diabetes, and
smoking cessation should be
encouraged.
Debridement – One of the major
mainstay treatment modalities is to
debride the necrotic and fibrinous
aspects of the wound to ensure
healthy granulated tissue can develop
[47].
Dressings – Venous ulcers should be
covered with one of the following
dressings [56]:
ŠŠ Occlusive dressing such as
a DuoDerm, Hydrasorb or a
Cutinova.
ŠŠ Polyurethane foam (such as
Allevyn).
ŠŠ After the dressing is applied, the
area is covered with a zinc paste
boot that will be changed weekly
[56].
Medications – The patient may be
prescribed metronidazole (Metrogel)
to reduce bacterial growth and odor
from the venous ulcer [56]. If the
patient has any erythemic dermatitis
of the skin, a medium-to-highpotency corticosteroid to decrease
the inflammation will be prescribed
[56]. There is insufficient evidence
supporting the use of systemic
antibiotics to improve the healing
of venous ulcers [15]. But many
researchers have speculated that
topical antimicrobial cleansers or
other formulations such as topical
cadexomer iodine may be effective
in treating venous ulcers. Further
research is required [15].
Other treatments – Other treatment
guidelines to prevent the exacerbation
of venous insufficiency and to
prevent the development of other
ulcers on the legs are [47]:
ŠŠ Elevate the legs above the level
of the heart while sleeping.
ŠŠ Avoid standing for long periods
of time.
Wound complications
There are a variety of complications that may
arise, depending upon the type of wound, injury,
co-morbidities and/or lifestyle of the patient.
In any acute wound, the biggest complication
is infection, including MRSA. If the acute
wound was induced by a laceration, abrasion or
puncture, other complications may arise when
Page 23
foreign bodies are dislodged, exacerbating a
potential infectious process, inflammation or
tissue damage. The most common generalized
complications that occur with any wound
are cellulitis, contact dermatitis, MRSA and
osteomyelitis.
Cellulitis
Cellulitis is an acute skin infection that spreads
rapidly and deeply from the dermis to the
subcutaneous tissue layers [19]. Soft tissue
cellulitis prolongs the inflammatory phase by
promoting tissue proteases, which inhibits the
ability of granulated tissue formation and delays
collagen deposits [81]. Cellulitis may occur after
a bite or any wound due to a bacterial or fungal
infection, especially Group A streptococcus and
staphylococcus aureus [51]. The most common
wounds that are prone to cellulitis include [6, 19]:
Animal bites.
Lacerations.
Ulcers.
Surgical wounds.
If a patient has cellulitis, the offending organism
invades the compromised area and overwhelms it
with neutrophils, eosinophils, basophils and mast
cells that break down the cellular components,
leading to inflammation [51]. The patient will
typically exhibit erythema, edema, warmth, pain,
fever and lymphangitis. Erysipelas is a superficial
form of cellulitis that involves the lymphatic
system and it is characterized by streaking lines
toward regional lymph nodes [19].
The most commonly affected sites include the
lower area of the body, although it can occur
anywhere [19].
Cellulitis is diagnosed by signs and symptoms
that are clinical features, and by cultures.
The laboratory data may demonstrate mild
leukocytosis and an elevated erythrocyte
sedimentation rate (ESR) demonstrating that
there is an inflammatory process occurring [19].
Cellulitis is typically treated with oral or IV
penicillin (PCN) to treat and eradicate the
most common organism staphylococcus and
streptococcus (gram-positive bacterias). The
health of the patient and the extent of the
cellulitis will determine the most effective course
of treatment.
Antimicrobial therapy.
ŠŠ Healthy adults with an uncomplicated
case of cellulitis should be prescribed
dicloxacillin 500 milligrams by mouth
four times a day or a cephalosporin, such
as cephalexin 250 to 500 milligrams four
times a day for seven to 10 days.
ŠŠ If the patient has a PCN allergy,
erythromycin (EES) should be
prescribed, 250 to 500 milligrams by
mouth four times a day.
ŠŠ If the patient has any co-morbidities or
is a complicated case (fever), he or she
should be prescribed ceftriaxone IV for a
few days, then an oral dose for seven to
10 days.
Other recommendations.
The patient should be encouraged to keep
the area elevated to promote comfort and to
decrease the edema [19]. Throughout the day,
the patient should apply warm moist heat or
soaks to alleviate the pain and to decrease the
edema by increasing the vasodilation process
[51].
Contact dermatitis
Contact dermatitis, also referred to as irritant
dermatitis or nonallergic dermatitis, is a chronic
inflammatory reaction that results from a
substance coming in contact with the skin [19].
The majority of patients described are at risk
of contact dermatitis caused by tape, cleansers,
soaps or dressings applied to their skin during
their treatment. The most common clinical
presentation of contact dermatitis is a pruritic
rash with erythema and/or vesicles, erosions or
crusting that may form over the area [19].
Contact dermatitis is typically diagnosed based
upon the clinical presentation and complaint of
pruritis from the patient. If warranted, cultures
and potassium hydroxide preparations can assess
for infectious or fungal contributing factors [19].
The treatment of contact dermatitis is to remove
and/or avoid the irritating, offending agent. Other
measures that should be implemented include
[19]:
Cleaning – Clean the area with mild soaps
and cleaning creams followed by lubrication
of the skin.
Medications – The patient should be
prescribed an anti-inflammatory to reduce
the inflammatory process and alleviate the
itching:
ŠŠ Oral glucocorticoid 1 milliliter per
kilogram tapered over two weeks.
MRSA
MRSA is a staphylococcus aureus infection that
is resistant to treatment with methicillin and
other similar drugs that typically and historically
treated staphylococcus infections. MRSA has
become prevalent in the community and hospitals
nationwide. The IHI’s 5 Million Lives campaign
for reducing the incidence and prevalence of
MRSA in the hospital and community settings
stated that in 2005, the CDC composed research
that demonstrated the following [42]:
There were over 94,000 invasive MRSA
infections in the United States population.
About 19,000 of the patients died (18
percent) during their initial hospitalization.
Approximately 75 percent were
uncomplicated bacteremias; others include
empyema, endocarditis and osteomyelitis.
Most invasive MRSA disease (about 86
percent) occurs in patients who are exposed
in hospitals or health care settings, while
about 14 percent occurs in persons without
recent hospitalization or other established
MRSA risk factors.
MRSA colonizes in the nares and skin and is
spread by lack of hand washing in conjunction
with altered immunity that may contribute to
other co-morbidities and/or breaks in the skin.
Patients at the highest risk of being affected by
hospital acquired MRSA include [42]:
Patients with other co-morbidities.
Patients who reside in a long-term care
facility or who have been hospitalized more
than 14 days. The Mayo Clinic stated that
in 2007, the Association for Professionals
in Infection Control and Epidemiology
estimated that 46 out of every 1,000 people
hospitalized are infected or colonized with
MRSA.
Patients with invasive catheters, including
but not limited to devices for dialysis, central
lines, and foley catheters.
Patients with recent antibiotic use.
MRSA typically presents as a spontaneous
appearance of a raised red lesion, surrounding
erythema with potential streaks, abscess and/or
purulent drainage with a fever [22, 69]. In order
to confirm the diagnosis, cultures are completed
immediately if MRSA is suspected. The
patient’s overall health condition and whether
hospitalization is required will determine the
treatment plan. If the patient is admitted to the
hospital, he or she will typically be prescribed
vancomycin. However, in 1997, a new strain
of MRSA was discovered that is resistant to
vancomycin, also known as vancomycinresistant enterococcus (VRE) [22]. If the patient
is in the community, the CDC recommends the
patient be prescribed clindamycin, tetracyclines
(doxycycline and minocycline), trimethoprimsulfamethoxazole (TMP-SMX), rifampin (used
only in combination with other agents), and
linezolid. [69].
In order to prevent transmission, all health
care workers should wash their hands, utilize
sterile techniques, keep the patient in isolation
and disinfect all materials that come in contact
with the patient. Patients should have their own
supplies while hospitalized, and they should
never be shared. [59].
Osteomyelitis
Osteomyelitis is a serious, potentially deadly
infection that is difficult to treat and eradicate.
Osteomyelitis is the spread of infection to the
bone and is prevalent among chronic non-healing
wounds. There are a few different types of
osteomyelitis [57]:
Hematogenous osteomyelitis is a bacteremia
that occurs in patients with sickle cell disease,
injection drug users and the elderly. The most
common source of bacteria is staphylococcus
aureus and P. aeruginosa.
Osteomyelitis from an infection such as a
prosthetic joint replacement, pressure ulcer,
surgery and trauma. The most common
source of bacteria is staphylococcus aureus or
staphylococcus epidermis.
Osteomyelitis associated with vascular
insufficiency occurs in patients with DM and
vascular insufficiency, especially in the foot
and ankle.
Patients are at risk of developing osteomyelitis if
they have any of the following risk factors [82]:
Bacteremia.
Peripheral vascular disease (PVD).
Page 24
Elite CME
DM.
Trauma.
Surgery.
Ulcers (pressure, diabetic, arterial/venous
leg).
The most common symptoms exhibited with
osteomyelitis are sudden pain and swelling in one
joint, fever or an associated ulcer or skin lesion
with possible drainage [82]. According to the
National Clearinghouse Guidelines, osteomyelitis
should be suspected in a chronic wound if any of
the following symptoms are exhibited [62]:
Bone exposed (or easily probed).
Tissue necrosis overlying bone.
Gangrene.
Persistent sinus tract.
Underlying open fracture.
Underlying internal fixation.
Wound recurrence.
If a patient has a diabetic foot ulcer, osteomyelitis
should be considered if the patient has any of the
following signs or symptoms [76]:
Deep or extensive ulcer, especially one that is
chronic or over a bony prominence.
An ulcer that does not heal after at least six
weeks of appropriate care.
Bone that is visible or can be palpated with a
metal probe.
A swollen foot with a history of foot
ulceration.
A red, swollen toe.
An unexplained high WBC or other
inflammatory markers such as CRP or ESR.
X-rays showing bone destruction beneath
an ulcer. X-rays and/or MRIs confirm the
diagnosis of osteomyelitis. If radiographic
findings suggest osteomyelitis, a histologic
evaluation and bone biopsy culture may be
considered.
The treatment of osteomyelitis includes surgery
to remove the infection in the bone, debridement
and prolonged systemic antibiotic therapy [38,
57]. Antibiotics usually are administered over
a course of four to six weeks depending on the
source of bacteria, extent of bone infection and
any co-morbidities. The most common antibiotics
to treat osteomyelitis are the following [82]:
Quinolones (ciprofloaxin 750 milligrams
twice a day).
Quinolone combined with rifampin 300
milligrams twice daily orally if the bacteria
source is staphylococcus aureus.
ŠŠ
ŠŠ
ŠŠ
ŠŠ
Always carry knives, scissors and or
any sharp object pointed downward.
Avoid keeping sharp objects in areas
in which children could access them.
Always wear shoes to avoid stepping on
something that may cause injury.
Promote the use of helmets and knee
pads when riding a bicycle, three/four
wheelers, rollerblades and a motorcycle.
The patient should be encouraged to
wear the appropriate size helmet.
Avoid picking up any broken glass or
razor blades with bare hands.
Children should always be in safe, sizeappropriate car seats facing the right
location and direction. According to the
American Academy of Pediatrics, the
following guidelines should be followed
related to car safety [2]:
Infants should be rear facing until
they are 1 year of age and weigh at
least 20 pounds.
Toddlers should ride forward facing
if they are at least 20 pounds.
School-age children should be in a
booster seat if they have outgrown
their forward-facing car seats.
Children should stay in a booster seat
until the adult seat belts fit correctly
(usually when a child reaches about
4 foot, 9 inches in height and is
between 8 and 12 years of age).
Older children who have outgrown
their booster seats should ride in a lap
and shoulder belt; they should ride in
the back seat until 13 years of age.
Bites
It is important to teach parents with children
common safe practices around animals and
recommendations if they are bitten [19, 27]:
The best preventive method is to avoid
aggressive behavior with animals and to
avoid unfamiliar animals.
Teach young children to avoid provoking
animals because it may lead to fewer
incidents of animal bites.
Never leave children unattended in the
presence of animals to potentially prevent
attacks.
Vaccinate all household animals for rabies.
In the United States, it is mandatory for all
domestic dogs and cats to be vaccinated
against rabies [19].
Prevention of wounds
If bitten, people should seek medical care
immediately. Research has demonstrated that
if the patient delays medical care for more than
24 hours, he or she is more likely to develop an
infection [27].
Depending on the social history of the individual;
the patient should be told [30, 35]:
To prevent abrasions, cuts, scrapes,
lacerations and/or punctures:
ŠŠ Avoid risky behaviors that can potentially
end in a dangerous situation.
ŠŠ Be careful with sharp objects, such as
knives, scissors, saws and trimmers.
In addition, patients who require sutures should
seek care within six hours of the injury to prevent
colonization of bacteria in the wound.
Nurses can potentially reduce the incidence
of illness through educating patients and their
families about various dangers from their
residence, occupation and hobbies.
Burns
In order to prevent burns, the patient should be
educated to [19]:
Turn off all electrical currents before
attempting any repairs.
Elite CME Keep protective covers in the outlets,
especially with children in the home.
Repair frayed electrical wires immediately.
Lower the water temperature in the home.
Avoid loose clothing when cooking.
Keep children away from the burners and
place all pans on the back burner with the
handle turned away from the front of the
stove.
Pressure ulcers
It cannot be stressed enough that pressure ulcers
can be prevented. It is important for nurses to
prevent pressure ulcers through good nursing
care, good nutrition, and maintaining proper
hygiene [57]:
Keep the skin and the bed linens clean and
dry at all times.
Any patient who is immobile, bedfast,
paralyzed, listless or incontinent should be
turned frequently, at least hourly.
ŠŠ Each time the patient is turned, his or her
skin should be reassessed to ensure that
there is no erythema or tenderness in any
areas of the skin.
ŠŠ Keep a written log to ensure
accountability of the staff to turn the
patient every hour.
Use appropriate mattresses, pillows and pads
to prevent patients at risk from developing
pressure ulcers.
Notify the doctor immediately if any
breakdown occurs on the skin.
Skin tears
Nurses and nursing assistants hold the biggest
key in preventing skin tears among the geriatric
population when they care for them in a facility
or at their home. In order to prevent skin
tears, the following recommendations should
be implemented, according to the National
Guideline Clearinghouse (2008) [63]:
Provide a safe environment.
ŠŠ Encourage patients to wear long sleeves
or pants to protect their extremities.
ŠŠ Ensure the room has adequate light to
reduce the risk of bumping into furniture
or equipment and have the call light
within reach.
Educate staff or family caregivers in the
correct way of handling patients to prevent
skin tears. Maintain nutrition and hydration
by offering fluids between meals, and use
lotion on arms and legs twice a day.
Protect from self-injury or injury during
routine care by:
ŠŠ Using a lift sheet to move and turn
patients and to enforce transfer
techniques that prevent friction or shear.
ŠŠ Pad bedrails, wheelchair arms and leg
supports.
ŠŠ Support dangling arms and legs with
pillows or blankets.
ŠŠ Use non-adherent dressings on frail skin.
ŠŠ Use gauze wraps, stockinettes or other
wraps to secure dressings rather than
tape.
ŠŠ Use emollient antibacterial soap when
cleaning the patient, and avoid any harsh
Page 25
chemicals that will exacerbate the effect
on the elderly patient.
Ulcers
Diabetic foot ulcers – According to the
American Academy of Family Physicians
(2005), patients can minimize their risk of
developing a diabetic foot ulcer by [38]:
ŠŠ Maintaining adequate blood glucose
control by adhering to their diet, exercise
regimen and taking any prescribed
medications. In addition, patients should
be instructed to see their PCP every three
months or as recommended by their PCP.
ŠŠ Performing daily self-inspections of the
feet and reporting any changes to their
health care professional.
Leg ulcers.
ŠŠ Venous ulcers – Compression stockings
are required to reduce the edema, thus
preventing the development of pressure
ulcers.
Legal issues revolving around chronic
wound care
Unfortunately, we live in a society that thrives
on finding errors by health care professionals
to be medical malpractice. One of the most
common lawsuits is related to chronic wounds,
such as pressure ulcers, foot ulcers and leg ulcers.
According to Medical News Today (2006) [58]:
More than 17,000 lawsuits are related to
pressure ulcers annually, the second-most
common claim after wrongful death and more
than those for falls or emotional distress.
Individual settlements range from under
$50,000 to as much as $4 million for each
case.
ŠŠ However, in 28 out of 30 plaintiff verdict
settlements in pressure ulcer lawsuits, the
average compensation was just less than
$1 million.
It is imperative that nurses recognize the risk
factors and symptoms for wounds to ensure
appropriate prevention and treatment modalities
are initiated. They also must understand the
importance of effective communication to
ensure that their colleagues know the importance
of turning a patient at least every two hours.
Although it is the duty of the physician to order
various diagnostic tests to potentially confirm a
diagnosis rather than speculate, the nurse is held
just as accountable to ensure the patient is safe at
all times.
Nurses have enormous responsibilities and
expectations bestowed upon them every time
they enter a facility and accept the responsibility
of care. In order for a nurse to prevent litigation
and potential harm to a patient, it is imperative
that each nurse be familiar with the policies,
procedures and laws that guide their practice.
Nurses can take action by adhering to the
following recommendations:
Obtain a copy of your nurse practice act for
the state or states in which you practice.
Understand and review the policies
and procedures at the facility to ensure
compliance.
Understand and review the standing protocols
and/or preventive protocols at the facility in
which you are employed to ensure that you
are abiding by the protocols.
Organizations
As professionals, it is important to be involved
in organizations that support the profession of
nursing and to be affiliated with organizations
based upon your areas of expertise. Nurses who
work in areas in which they are responsible
for caring for patients with wounds would
benefit from becoming certified in wound care
to enhance their credibility and to ensure that
the nurse is continuously receiving the latest
guidelines and research. Due to the ever-changing
medical field and the vast array of wounds that
may be presented, being certified and affiliated
with organizations will be beneficial to the nurse,
the profession and the patients that we serve.
Here are some organizations that are available for
nurses to join [70]:
American Academy of Wound Management
(AAWM) is a national, voluntary, nonprofit,
multidisciplinary certifying board for health
care professionals involved in wound care.
The purpose of AAWM is to establish and
administer a certification process to elevate
the standard of care across the continuum
of wound management. The academy is
dedicated to an interdisciplinary approach in
promoting prevention, care, and treatment of
acute and chronic wounds.
The American College of Certified Wound
Specialists (ACCWS) is a membership
organization that serves as an educational
resource.
Wound, Ostomy and Continence Nursing
Certification Board (WOCNCB) is the
only organization that offers wound care
certification exclusively to nurses. The goal
of the WOCNCB is to set, maintain and
evaluate national standards for certification
and re-certification in wound, ostomy and
continence nursing care.
National Alliance of Wound Care (NAWC)
is a nonprofit, national multidisciplinary
wound-care certification board and a woundcare professional membership organization.
The goal of the NAWC is dedicated to the
advancement and promotion of wound care
through the certification of wound-care
practitioners in the United States.
Closing
Wound care remains a complex concept to
grasp and understand because there are so
many different types of wounds and treatment
modalities. Nurses do not have control of the
lifestyle choices that people make to put them at
risk for acute wounds. However, we can control
and prevent perineal skin breakdown, skin tears
and pressure ulcers for any patient under our
care or whom we are discharging home with a
caregiver. It is imperative that nurses remain
knowledgeable and attuned to evidence-based
practice guidelines while caring for all patients
to ensure that the care provided is efficient in
preventing and managing any particular wound.
There are many organizations researching and
providing evidence-based practice guidelines
and protocols; nurses need to ensure that they are
adhering to guidelines of the facility where they
are employed and credible sources alluded to
throughout this continuing education.
Table 1 – Progression of decubitus ulcers
[59]
68]
Table 2 – Diabetic foot ulcer
Typical diabetic foot ulcer caused by high plantar
pressures at the second metatarsal head. [34]
Table 3 – Venous ulcers
[85]
Table 4 – Arterial ulcers
[85]
Page 26
Elite CME
Table 5 – CDC Tetanus schedule
Vaccination
history
Clean, minor
wounds
All other
wounds
Unknown or
less than 3
doses
Td or Tdap
(Tdap
preferred for
ages 11-18)
Td or Tdap
(Tdap
preferred for
ages 11-18)
Plus tetanus
immune
globulin (TIG)
3 or more
doses and
less than 5
years since
last dose
3 or more
doses and
6-10 years
since last
dose
3 or more
doses and
more than 10
years since
last dose
[21]
Td or Tdap
(Tdap
preferred for
ages 11-18)
Td or Tdap
(Tdap
preferred for
ages 11-18)
Td or Tdap
(Tdap
preferred for
ages 11-18)
Table 6 – Vacuum assisted closure mechanism
Figure 4: Principles of action of the VAC therapy
device (with permission of KCI Europe). [31]
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97. Wound Care Information Network (2008). Venous Ulcerations. Retrieved online May 28, 2008
at http://www.medicaledu.com/venous.htm
98. WoundHeal (2008). Biocore decision trees for the wound heal solution: Chronic and acute
wounds. Retrieved online May 29, 2008 at http://www.woundheal.com/products/ decissionTree.
htm
99. Wound Research. (May 2008). Diabetic Foot Ulcers. Wounds (20), 5; 110.
Page 27
WOUND CARE
Self Evaluation Exercises
Choose True or False for questions
1 through 10 and check
your answers at the bottom of the page.
10. The most common generalized
complications that occur with any wound
are cellulitis, contact dermatitis, MRSA and
osteomyelitis.
True
NOTES
False
1. The epidermis is the most important layer
of the skin because it is on the outside.
True
False
2. Stratum granulosum consists of a single
layer of low columnar stem cells and
keratinocytes on the basement membrane.
True
False
3. First intention healing involves the primary
closure of the wound by mechanical
mechanisms, such as tape, sutures, staples
or glue.
True
False
4. A patient who weighs more than 20 percent
of his or her ideal body weight is at greater
risk of dehiscence, herniation and infection,
thus exacerbating the wound healing
process.
True
False
5. Pregnant women are at greatest risk of
developing a skin tear.
True
False
6. It is important to assess the mechanism of
an injury because it helps to determine the
presence of foreign bodies or the prognosis
for developing an infection or scar.
True
False
7. A stage 3 pressure ulcer is a partial
thickness that involves the epidermis,
dermis layer or both.
True
False
8. Debridement is a method of treatment
to clean or remove necrotic, dead tissue
so that granulation can occur to improve
wound healing.
True
False
9. In order to properly clean a pressure ulcer,
normal saline (NS) should be utilized.
True
False
1.T 2.F 3.T 4.T 5.F 6.T 7.F
8.T 9.T 10.T
Answers:
Page 28
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