Chapter 8 Condensed- Wound Care

Chapter 8 — Wound Care: Objective-Focused Study Guide

1. Preventing Pressure Injuries

Know the major causes: pressure, friction, shear, moisture/microclimate, immobility, poor nutrition/hydration, impaired sensation, altered mental status, impaired perfusion, older age, and medical devices.

Key nursing interventions:

• Assess pressure-injury risk on admission and regularly afterward.

• Inspect skin at least daily, especially bony prominences and beneath medical devices.

• Reposition routinely according to patient condition and risk.

• Use approximately 20–30° side-lying, rather than 90°.

• Keep HOB at or below 30° when medically appropriate to reduce shear.

• Promote early mobility and ambulation.

• Use pressure-redistribution mattresses, cushions, heel-elevation devices, and positioning wedges.

• Do not use donut/foam-ring devices.

• Keep skin clean and dry; manage urine, stool, sweat, drainage, and other moisture.

• Use low-friction linens and safe lifting/transfer techniques rather than dragging the patient.

• Support adequate calories, protein, fluids, vitamins, and minerals.

• Correctly size medical devices and inspect the skin underneath them.

• Teach the patient/caregiver how to participate in prevention.

Pressure-injury stages to recognize

Major safety point: Stable, dry, adherent heel eschar without erythema or fluctuance should not be removed or softened.

2. Cleaning a Wound and Applying a Dry Sterile Dressing

Before beginning

• Verify the prescribed wound care.

• Assess pain and give prescribed analgesia early enough to work.

• Perform hand hygiene.

• Apply appropriate PPE.

• Position and drape the patient.

• Place a waterproof pad under the site.

• Assess any tubes/drains before removing the old dressing.

Removing the old dressing

1. Put on clean gloves.

2. Loosen adhesive in the direction of hair growth.

3. Carefully remove dressing.

4. If stuck, moisten with sterile saline rather than pulling.

5. Observe drainage:

   • Amount

   • Color

   • Odor

   • Consistency

6. Discard dressing.

7. Remove gloves.

8. Perform hand hygiene.

Assess the wound

Document:

• Location

• Length × width × depth

• Wound edges/approximation

• Granulation tissue

• Slough

• Eschar

• Necrosis

• Tunneling/undermining

• Drainage

• Odor

• Surrounding skin

• Pain

• Signs of infection

Cleaning

For a sterile dressing procedure, prepare a sterile field and use sterile supplies.

General rule:

Clean from least contaminated → most contaminated.

For an approximated incision:

• Clean top to bottom.

• Work outward from the incision.

• Use a new gauze/swab for every stroke.

For an open/unapproximated wound:

• Begin at the wound edge.

• Clean outward in circular strokes.

• Use a new gauze/swab for each circle.

Applying the sterile dressing

• Dry surrounding skin, not the wound bed.

• Apply prescribed medication/product if ordered.

• Place the prescribed sterile dressing over the wound.

• Dressing should extend at least 1 inch beyond wound edges.

• Apply a secondary dressing if required.

• Secure without excessive tension.

• Label dressing with date and time.

• Reposition patient safely.

• Perform hand hygiene.

Key principle

Never move a contaminated swab back over an area you already cleaned.

3. Collecting a Wound Culture

Purpose

Identify the causative organism so appropriate antimicrobial treatment can be selected.

Important

When possible, obtain the culture before antimicrobial therapy begins.

Correct procedure

1. Verify order.

2. Assess pain and medicate if needed.

3. Remove old dressing with clean gloves.

4. Observe drainage.

5. Remove gloves and perform hand hygiene.

6. Clean the wound with saline without preservatives.

7. Dry the surrounding skin.

8. Use aseptic technique.

9. Select a 1-cm² area of viable tissue free from necrosis.

10. Press the swab firmly enough to express wound fluid.

11. Rotate the swab for approximately 5 seconds.

12. Avoid touching intact surrounding skin or wound edges.

13. Place swab into culture tube without contaminating the outside.

14. Label specimen correctly.

15. Place in biohazard bag.

16. Transport promptly.

NCLEX trap

Do not swab old pus or drainage sitting on the wound.

Clean the wound first, then culture viable tissue.

4. Wound Irrigation

Purpose

Irrigation removes:

• Debris

• Exudate

• Pathogens

while minimizing trauma to healthy tissue.

Important numbers

• Ideal irrigation pressure: 5–15 psi

• Common equipment: 18–19 gauge angiocatheter/needle

• Syringe: 30–35 mL

• Common solution: 0.9% normal saline

Procedure

1. Verify prescription.

2. Assess the wound and pain.

3. Administer analgesic if required.

4. Position patient so fluid flows from clean area toward dirty area.

5. Protect the bed and patient with waterproof pad/draping.

6. Use required PPE, including splash protection.

7. Remove old dressing and assess drainage/wound.

8. Perform hand hygiene.

9. Prepare sterile irrigation solution and supplies as indicated.

10. Place collection basin below wound.

11. Irrigate using pulsatile or continuous flow.

12. Direct solution top to bottom through all wound areas.

13. Continue until return fluid runs clear.

14. Clean and dry surrounding skin.

15. Redress the wound.

Stop the procedure if:

• New bleeding occurs.

• Significant pain develops.

For new bleeding:
Stop → assess → obtain vital signs → notify health care team → document.

5. Emptying Wound Drainage Using Medical Asepsis

Even though we are excluding Penrose, Jackson-Pratt, and Hemovac-specific care, you should still know the general objective of safely handling drainage.

Use medical asepsis to prevent transmission of microorganisms.

Core principles:

• Perform hand hygiene.

• Wear clean gloves.

• Avoid contaminating the drainage outlet or collection equipment.

• Prevent drainage from contacting your hands, clothing, linens, or surrounding environment.

• Measure drainage using the appropriate graduated container.

• Assess and record:

  • Amount

  • Color

  • Character/consistency

  • Odor when relevant

• Dispose of drainage according to facility policy.

• Clean equipment as required.

• Remove gloves.

• Perform hand hygiene.

• Document output accurately.

Drainage identification

Unexpected increases in bloody drainage, purulent drainage, or major changes in output require further assessment.

6. Heat Therapy

Effects of Heat

Heat causes vasodilation.

Effects include:

• ↑ Blood flow

• ↑ Oxygen and nutrient delivery

• ↑ metabolism

• ↓ muscle tension

• ↓ muscle spasms

• ↓ joint stiffness

• ↓ pain

• Promotion of healing

Temperature

Water used for heat applications:

105–109°F (40.5–43°C)

Do not exceed 120°F (49°C).

Typical duration

20–30 minutes

Beyond this period, the rebound phenomenon can occur and prolonged heat may cause tissue congestion, vasoconstriction, burns, and tissue injury.

Heat safety

Before applying, assess:

• Skin

• Circulation

• Sensation

• Mental status

• Age

• Condition of equipment

High-risk patients include:

• Older adults

• Young children

• Patients with diabetes

• Peripheral neuropathy

• Stroke/spinal cord injury

• Impaired circulation

• Decreased sensation

• Cognitive impairment

• Thin/damaged skin

Do not apply heat to:

• Acute hemorrhage

• Immediately after traumatic injury to an open wound

• Acutely inflamed areas

• Certain areas with impaired circulation

• Localized malignancy

• Pregnant abdomen

• Testes

• Areas over metallic implants, according to the textbook guidance

External heating pad

• Never place underneath the patient.

• Never allow patient to lie on it.

• Cover the device.

• Do not use pins.

• Assess skin frequently.

• Do not increase temperature simply because the patient says it no longer feels warm.

7. Warm Moist Compress

Moist heat:

• Promotes circulation

• Promotes healing

• Reduces edema

• Reduces pain

• Penetrates tissues more deeply than dry heat

Temperature:

105–109°F

Duration:

Up to 20–30 minutes

Because moisture conducts heat, a lower heat setting may be necessary when an external heating device is used over a warm compress.

Monitor frequently for:

• Excessive redness

• Swelling

• Pain

• Burning

• Skin injury

8. Cold Therapy

Cold causes vasoconstriction.

Effects:

• ↓ Blood flow

• ↓ edema

• ↓ inflammation

• ↓ pain-producing substances

• ↓ muscle spasms

• ↓ sensation/pain

• Helps limit bleeding and hematoma formation

Common uses include:

• Acute trauma

• Sprains

• Muscle spasms

• Dental pain

• Some chronic pain conditions

Technique

• Fill ice bag about ⅔ full.

• Remove excess air.

• Seal securely.

• Cover with towel/washcloth.

• Place on treatment site.

Immediate safety assessment

After about 30 seconds, temporarily remove the cold source and assess:

• Redness

• Burning

• Sensation

If safe, replace it.

Duration

Generally:

Up to 20 minutes

Allow at least:

20–30 minutes between applications.

Stop cold therapy for:

• Pallor

• Cyanosis

• Burning

• Increasing pain

• Altered sensation

• Sluggish capillary refill

• Excessive numbness

Most Important Numbers