Wound Care and Skin Integrity

Patient Assessment and Hospital Accountability

• Pruritus and skin integrity: Patients scratch frequently; scratching can lead to skin breakdown and scaleless skin. Practical implication: encourage adequate hydration and comfort measures to reduce scratching and subsequent skin injury.

• Hospital liability and billing: Any infection or wound acquired after admission can implicate the hospital for associated care costs. The hospital is generally expected to cover care for wound-related needs that are attributed to the facility; insurers may not reimburse if the wound is facility-caused and not documented at admission. Key takeaway: perform a thorough admission body assessment to establish a clear baseline and reduce liability.

Wound Surveillance and Documentation

• Avoid superficial assessments: Do not perform a quick overhaul and assume the wound is under control. Document status comprehensively at intake and with ongoing checks.

• Documenting wound size and progression: When assessing a wound, outline or mark the wound with a pen to track bleeding and changes over time. This creates a benchmark for monitoring progression.

  • Example: If you return in 10 minutes and blood has spread beyond the drawn line, compare to prior size. A change from roughly a quarter-sized area to a larger area (e.g., orange-sized) indicates worsening bleeding and may require escalation.

• Time frame and escalation: Use clear time marks to assess progression (e.g., 10 minutes) to determine if the wound is stable or expanding.

Dehiscence and Evisceration: Emergencies and Immediate Actions

• Terms: Disceroration appears to refer to wound dehiscence (the wound edges pulling apart). Evisceration is when internal organs (e.g., intestines, liver) protrude through the wound.

• Immediate management of suspected dehiscence or evisceration:
  1) Do not delay reporting the situation; call the provider immediately.
  2) If tissue or organs are protruding, cover the exposed area with sterile wet gauze moistened with saline to protect tissues and reduce contamination.
  3) Activate the surgical team and prepare for return to the operating room (OR) for surgical management.

• The goal is rapid stabilization and definitive surgical repair due to the medical emergency nature of open wound contents.

Wound Healing Stages and Staples Management

• Healing stages: The transcript mentions a progression to Stage IV healing; implies monitoring progression from Stage I toward Stage IV.

• Staple management: If a wound is closed with staples, count and track how many staples are present, because they must be removed later. Example: a wound with 12 staples would require removal of all 12 staples.

• Depth assessment and tunneling:

  • Depth and contour can be measured with a cotton swab (Q-tip) to assess for depth and potential tunneling.

  • If tunneling or complex depth is present, document and adjust care accordingly.

• Positioning and pressure relief for deep or sacral/abdominal wounds: For wounds in folds or pressure-prone areas (e.g., sacral, abdomen folds), use positioning aids (e.g., pillowcases) to reduce moisture buildup and pressure.

Wound Assessment Techniques and Anatomy

• Depth measurement technique: Use a cotton swab to gently measure wound depth; insert into the deepest accessible point to obtain a depth measurement.

• Tunneling and undermining: Assess for tunnels or undermining routes which may require specific dressing strategies or wound care plans.

• Addressing moisture and skin protection: In areas with sweating or moisture (e.g., abdominal folds, skin folds), implement strategies to protect skin and reduce maceration.

Pain Management and Dressing Timeframes

• Dressing duration and timing: If a wound dressing will require a prolonged dressing change, plan for pain management ahead of time.

• Pain medications: If the patient does not have appropriate pain control, arrange for orders to ensure comfort during dressing changes and wound care.

Infection Prevention and Dressing Protocols

• Infection prevention basics: Emphasize proper hand hygiene, proper use of supplies, and correct glove changes.

• Dressing frequency and styles:

  • Dressings are typically performed twice daily in many facilities.

  • Use negative pressure dressings (NPWT) when indicated to promote wound healing and manage exudate.

  • Transparent dressings are commonly used to cover IV sites while allowing visibility.

  • Gauze dressings are used as part of standard wound care, with attention to keeping the area clean and sterile.

• Procurement and protocol notes: Ensure appropriate supplies are available, including sterile saline for irrigation, sterile gauze, and the correct type of dressing for the wound and its stage.

Special Considerations: Positioning, Fungal Presence, and Long Dressing Times

• Pressure and moisture management: For wounds in heavy moisture areas or folds, use protective positioning and skin care to minimize maceration and infection risk.

• Fungus and skin integrity: If a fungal infection is suspected or present, antifungal powder or appropriate antifungal treatment may be considered as part of skin care; ensure orders are in place and that wound care continues with attention to fungal colonization.

• Time-intensive dressing changes: Recognize that some wounds will require long dressing sessions. Plan patient comfort, analgesia, and nursing staffing accordingly.

Practical Implications: Ethics, Accountability, and Real-World Relevance

• Ethical practice: Thorough assessment at admission and careful ongoing documentation protect patient safety and reduce hospital liability related to wound care borne by the facility.

• Accountability in care: Clear documentation, measured wound progress, and appropriate escalation pathways ensure timely intervention and continuity of care.

• Real-world relevance: The described practices reflect common hospital wound care processes, including infection prevention, wound measurement, dehiscence/evisceration management, pain control, and use of advanced dressings such as NPWT.

Quick Reference: Key Measurements and Values

• Bleeding progression indicators: From approximately a example: {quarter-sized} area to example: {orange-sized} area indicates increasing bleeding, prompting escalation.

• Staples management: Common numbers may include 12 staples; staples should be counted and tracked for removal.

• Depth assessment: Depth measured with a cotton swab; document explicit depth value (e.g., in cm or mm) for wound depth and potential tunneling.

• Healing stage references: Mention of Stage I progressing to Stage IV healing; use established clinical definitions in your setting for precise staging.