Comprehensive Guide to Nursing Skills and Procedures

Hemostasis

Right after injury - body stops bleeding by clotting.

Inflammation

1-5 days - red, swollen, warm, painful. Body fights infection.

Proliferation

5-21 days - new tissue grows (like scaffolding), skin starts to heal.

Maturation (Remodeling)

Weeks to a year - scar tissue forms, wound fully closes.

Partial-thickness

Skin surface (top layers).

Full-thickness

Goes deep into fat/muscle.

Surgical

Planned cut/incision during surgery.

Traumatic

Accidental injuries (e.g. cuts, abrasions).

Pressure injuries

Caused by prolonged pressure, usually over bony areas.

Diabetic ulcers

Caused by nerve damage + poor blood flow.

Venous ulcers

Poor return of blood from legs.

Arterial ulcers

Caused by blocked arteries and poor circulation.

Clean

No germs, no infection.

Clean-contaminated

Controlled entry into the respiratory, genital or urinary tract without major contamination.

Contaminated

Dirty wound or open injury.

Infected

Pus or signs of infection, or tissue death.

Serous

Clear, watery fluid.

Serosanguinous

Pinkish, watery blood mix.

Sanguineous

Red, watery bleeding.

Purulent

Yellow/green, thick, pus (infected).

Tophi

White, thick (urate crystals - gout).

Granulation

Bumpy, red/pink healthy healing tissue.

Hypergranulation

Too much granulation tissue.

Slough

Yellow/gray, soft stringy dead tissue.

Eschar/Necrotic

Thick black or brown dead tissue.

Epithelialization

Pink new skin growing over the wound.

Maceration

Water-logged, soft, white skin.

Erythema

Redness.

Induration

Hard around the wound.

Callous

Thickened skin from friction/pressure.

Undermining

Wound extends under the skin edges.

Tunneling

Wound forms a narrow passage into deeper tissues.

Moisture Management

Keep the wound moist, not wet. Moisture supports cell growth and healing.

Debridement

Removing Dead Tissue.

Autolytic

Body breaks down dead tissue itself.

Mechanical

Physical removal using Wet-to-dry dressings, or irrigation.

Enzymatic

Uses topical enzymes to dissolve necrotic tissue.

Biological

Medical maggots or leeches, Eats only dead tissue.

Irrigation

Use normal saline to cleanse the wound and remove debris, avoid cytotoxic solutions like hydrogen peroxide unless specifically indicated.

Odor Control

Use charcoal or silver dressings (e.g., Actisorb Silver) if the wound has a strong smell.

Negative Pressure Wound Therapy (NPWT)

Suction removes fluid, pulls edges together, and stimulates healing.

Offloading and Pressure Relief

Float heels, turn q2h, use air mattresses or foam cushions.

Factors Influencing Wound Healing

Patient-Related: Age, nutrition, hydration, comorbidities (e.g., diabetes), smoking status, and mobility.

T.I.M.E. Framework

The T.I.M.E. framework helps you assess and manage wounds by focusing on four key components that must be optimized for healing.

T.I.M.E. Framework - T

Tissue (Non-viable or Deficient?) Goal: Remove dead (non-viable) tissue to promote healing.

T.I.M.E. Framework - I

Infection or Inflammation Goal: Reduce infection and control inflammation.

T.I.M.E. Framework - M

Moisture Balance Goal: Keep the wound moist but not too wet.

T.I.M.E. Framework - E

Edge of Wound (Advancing or Not?) Goal: Get the wound edges to migrate and close.

Phases of Wound Healing - Hemostasis

Occurs immediately after injury, Platelets form clots and stop bleeding, Blood vessels constrict briefly.

Phases of Wound Healing - Inflammation

1-5 days, Redness, swelling, pain, warmth, White blood cells fight bacteria and remove debris.

Phases of Wound Healing - Proliferation

5-21 days, Granulation tissue forms, Collagen builds new tissue, New blood vessels form (angiogenesis), Epithelial cells resurface the wound.

Phases of Wound Healing - Maturation/Remodeling

Weeks-months, Collagen is reorganized, Scar strengthens over time, May take up to 1 year.

Partial-Thickness Wounds

Involves epidermis and part of dermis, Usually heals by regeneration. EX: Stage 2 pressure injury.

Full-Thickness Wounds

Involves epidermis, dermis, subcutaneous tissue, and possibly muscle/bone, Heals by scar formation, EX: Surgical wound with deep tissue exposure.

Wound Debridement - Autolytic

Uses body's own enzymes/moisture.

Wound Debridement - Surgical

Cutting out dead tissue with scissors or scalpel, Requires trained professional.

Wound Debridement - Mechanical

Physical removal (e.g., wet-to-dry dressings, wound irrigation).

Factors Delaying Wound Healing - Poor perfusion

Less oxygen and nutrients to tissue.

Factors Delaying Wound Healing - Infection

Prolongs inflammation and tissue damage.

Factors Delaying Wound Healing - Diabetes

Impairs circulation and immune response.

Factors Delaying Wound Healing - Smoking

Reduces oxygen and delays cell repair.

Infusion Therapy

The administration of fluids, medications, blood products, or nutrients into the bloodstream or body tissues.

Hypodermoclysis (HDC)

A method of administering fluids subcutaneously.

Hypodermoclysis

Subcutaneous infusion of fluids.

Indications for Hypodermoclysis

Mild to moderate dehydration, especially in older adults, palliative care clients, patients with poor IV access, and clients in long-term care.

Contraindications of HDC

Severe dehydration or shock, need for rapid fluid replacement, bleeding disorders, local skin infections.

Advantages of HDC

Less invasive and painful than IVs, fewer complications, easy to initiate and manage, can be used at home or in LTC, safer for frail or elderly clients.

Disadvantages of HDC

Slower absorption than IV, not suitable for emergency or rapid fluid replacement, volume limits per site (usually 1-2 mL/min; max ~1.5-3 L/day depending on patient and site).

Common Sites for Hypodermoclysis

Abdomen (most common and comfortable), thighs (good for mobility-limited clients), upper arms (alternate site), upper back (used when others are not suitable).

Fluids Commonly Used

Normal saline (0.9%), Half Normal Saline (0.45%), D5W (Dextrose 5% in water).

Administration Tips for HDC

Use butterfly needle or small gauge (24-27G), warm fluid before starting, elevate bag above insertion site, use infusion pump if ordered or gravity with flow control.

Additives in HDC

Hyaluronidase (sometimes used): helps spread fluid into tissue faster (not always available).

Monitoring in HDC

Local edema, redness, pain, leaking, infection, absorption, patient discomfort.

When Is HDC Most Commonly Used?

Palliative care, elderly clients in LTC, dehydrated clients with poor veins, clients refusing IVs.

Documentation for HDC

Site used, solution type and volume, rate of infusion, patient's tolerance, site condition and skin integrity.

Equipment Needed for HDC

Subcutaneous infusion set (e.g., butterfly needle), appropriate fluid bag, tubing and connectors, alcohol swabs, transparent dressing, infusion pump or gravity setup.

Procedure for HDC

Verify physician's order, perform hand hygiene and don gloves, select and prepare the infusion site, clean site with alcohol swab for 30 secs, let dry, insert the needle at a 45-degree angle, secure the needle with a transparent dressing, connect tubing and start infusion at prescribed rate, monitor the site and patient response.

Infusion Rates

Typical rate: 30-50 mL/hr; Maximum volume: 1,000-1,500 mL per 24 hrs.

Interventions for HDC

If complications arise, discontinue infusion and notify HCP, rotate sites if needed, ensure proper technique and equipment usage.

Common Sites for Subcutaneous Infusion

Abdomen (most common and well tolerated), lateral thighs, upper arms (posterior area), upper back (especially in frail or bed bound clients).

Typical Rate of Infusion

30-50 mL/hr.

Maximum Volume for Infusion

1,000-1,500 mL per 24 hrs.

Patient Monitoring in HDC

Monitor for local edema, redness, pain, leaking, infection, absorption, and patient discomfort.

Comfort in HDC

Hypodermoclysis is ideal for hydration when comfort, ease, and safety are more important than speed.

Steps for initiating hypodermoclysis infusion

1. Gather supplies: IV fluid bag (e.g., NS), butterfly needle (24-27G), tubing, dressing; 2. Wash hands and don gloves; 3. Select site (abdomen, thigh, arm, back); 4. Clean site with antiseptic using aseptic technique; 5. Insert butterfly needle into subcutaneous tissue at 45-90° angle; 6. Secure needle and connect tubing; 7. Start infusion (via gravity or pump); 8. Label site and monitor for swelling, redness, or leakage; 9. Document site, solution, rate, patient tolerance.

Complications of hypodermoclysis

Local swelling or edema, redness or irritation, leakage of fluid at insertion site, pain or discomfort, infection.

IV Therapy

The administration of fluids, medications, or nutrients directly into a vein.

Uses of IV Therapy

Hydration, medication delivery, blood transfusions, electrolyte balance, emergency interventions.

Isotonic IV Solutions

Normal Saline (0.9%), Lactated Ringers; used for fluid replacement; same tonicity as blood.

Hypotonic IV Solutions

0.45% NS, D5W; used for dehydration in cells (pulls fluid into cells).

Hypertonic IV Solutions

D5NS, D10W; used for pulling fluid out of cells - used with caution.

Phlebitis

Red, warm, tender vein; if occurs, stop infusion, remove IV, apply warm compress.

Infiltration

Cool, swollen, pale site; if occurs, stop infusion, elevate, apply warm compress.

Fluid overload

Symptoms include crackles, SOB, edema; if occurs, slow or stop infusion, notify team.

IV Flow Rates

Gravity drip: count drops per minute (gtt/min); Pump infusion: set in mL/hour.

Indwelling catheter (Foley)

A soft tube placed through the urethra into the bladder, held in place by a balloon; used for urinary retention, during/after surgery, strict I&O monitoring, skin breakdown from incontinence, end-of-life care.

Advantages of Foley catheter

Continuous drainage, accurate output monitoring, can stay in place for days/weeks.

Disadvantages of Foley catheter

Higher risk of CAUTI, can cause urethral trauma, reduced mobility.

Nursing Care for Foley catheter

Secure catheter, keep bag below bladder, empty q8h or when ¾ full, clean perineum and tubing daily, assess for infection.

Common Urinary Catheter Sizes

Adult Female: 14-16 Fr; Adult Male: 16-18 Fr.