Chronic wounds represent a devastating health care problem with significant clinical, physical and social implications. Evidence suggests that consistent, meticulous and skilled care provides the primary means by which successful wound care and healing is promoted. The occurrence of wounds has plagued humankind throughout recorded history and remains a major source of morbidity and mortality in several disciplines of clinical medicine. Within this thesis, an effort will be made to address the basics of appropriate and potentially successful nursing in wound care and the promotion of healing. Section 1 will provide introductory information on the problem of wound care. In Section 2, the relevant literature will be reviewed while Section 3 will present the research methodology used within the thesis. In Section 4, the results of the thesis will be provided, offering a framework that can be used for insuring that the essential basics in wound care are provided by nurses. Section 5 will offer conclusions based on the thesis.
Basic principles of wound care have been established that serve as a model for managing wound and delivering wound care services and treatment (Dickerson, Purdue & Hunt, 1999). These principles include adherence to a wound care strategy that recognizes that as with any injury, priorities are given to life-threatening conditions, which are managed accordingly. As well, as outlined by Dickerson et al., all patients should be considered to have potential risk for communicable diseases with Universal Precautions taken when providing direct patient care.
As suggested by Dickerson et al. (1999), initially it is important to note the depth of injury, as determined by loss of function of the injured part as well as injury to underlying nerves, blood vessels, tendons, bones, and joints. As well, knowledge of the duration of the time that has elapsed since the injury occurred is also critically important. According to Dickerson et al., an overall assessment should be completed including nutritional status as well as general medical condition, with particular attention given to systemic factors such as diabetes mellitus, peripheral vascular disease, bleeding disorders, and immunotherapy or steroid therapy that alter the body’s capability to respond to injury and may impede wound healing.
As explained by Dickerson et al. (1999), wound care efforts are directed at methods and techniques which prevent infection, facilitate wound healing, promote comfort, and at the same time, maintain optimal function and minimize deformities.
The basic types of wound care injuries include soft tissue injuries can be roughly divided into simple open wounds with minimal soft tissue damage and wounds with major soft tissue damage. Wounds with major soft tissue damage are burn wounds, avulsive injuries, crush injuries, and amputations. As well, cecrotizing infections also create wounds with extensive skin loss, which fall into the category of major tissue damage.
As explained by Dickerson et al. (1999), models of wound care management are based on a strategy for the practical management of wounds, implemented and based on knowledge of the nature of the injury, functional anatomy, and the wound healing process. According to Dickerson et al., understanding the mechanism of injury helps explain the type of wound, determine the nature and extent of damage, identify common injury combinations, and predict eventual outcome.
According to Fishman (2003), important to a model of would management is a recognition that the entire wound healing process is a complex series of events that begins at the moment of injury and can continue for months to years. The wound healing phases as identified by Fishman include the following:
I. Inflammatory Phase
A) Immediate to 2-5 days
Thromboplastin makes clot
II. Proliferative Phase
A) 2 days to 3 weeks
Fibroblasts lay bed of collagen
Fills defect and produces new capillaries
Wound edges pull together to reduce defect
Crosses moist surface
Cell travel about 3 cm from point of origin in all directions
III. Remodeling Phase
A) 3 weeks to 2 years
B) New collagen forms which increases tensile strength to wounds
C) Scar tissue is only 80% as strong as original tissue
Recent estimates suggest that 1% of the total health care dollar is spent on wound care in the U.S. (Lane, 1995). While this figure seems relatively small and inconsequential, many of individual costs associated with wound care are massive.
Approximately $1.36 billion is spent on pressure ulcer treatment (U.S. Department of Health and Human Services [USDHHS], 1994). Similar estimates have also suggested that the average cost to heal a single pressure ulcer ranges from $1,951 for a leg ulcer to $29,373 for a diabetic ulcer (Bolton, Van Rijswijk, & Shaffer, 1996). Foot ulcers are the number one reason for hospitalization of diabetic patients and are the major cause of non-traumatic amputations. Diabetic amputations average 67,000 procedures per year at a cost of $98 billion in health care dollars (Burdette-Taylor, 1999; USDHHS Diabetes Surveillance, 1997).
Similarly, lengthy hospital stays are often experienced by patients with pressure ulcers who frequently remain hospitalized for more than 35 days (O’Brien, Gahtan, Wind, & Kerstein, 1999). Chronic non-healing wounds, most often associated with inadequate blood flow, are suffered by an estimated five million people in the U.S. (Liang, 1999). The number of those affected by chronic wounds is increasing at an annual rate of 10%. Venous ulcers account for 80% to 90% of all lower extremity ulcers (Neil, & Munjas, 2000). On the basis of available Medicare data, more than $20,000 is spent per patient, per ulcer episode, including at least one hospital stay and home visits (Liang, 1999). An estimated $5 billion to $7 billion is spent on chronic wound treatment annually in the U.S. (Morgan, & Hoelscher, 2000).
As evidenced within the literature, on wound care, estimates such as the above only represent the costs that are most widely visible. Such estimates fail to account for the hidden costs that patients and families must endure, including loss of work and self-esteem, social isolation, depression, increased stress, and adaptation to demands of daily living. As well, the costs associated with caregiving are also extensive as this type of care is not only time-consuming, but emotionally and physically draining. The cost to nursing staff can lead to increased stress, frustration, and burnout due to the chronic nature of many wounds. As the estimates of incidence and prevalence of pressure ulcers become more widely known, the costs of care also become more readily observable. As reported by Dwyer and Keeler (1997), currently, rates for pressure ulcers in skilled care and nursing home facilities approach 23%. It has also been documented that critical care patients represent a large proportion of hospitalized patients with pressure ulcers: 33% incidence and 41% prevalence (Beitz, Fey, & O’Brien, 1998). According to Carlson, Kemp and Short (1999), the prevalence of pressure ulcers is 3% to 30% in the general population and 17% to 56% in critically-ill patients (Carlson, Kemp, & Short, 1999). As indicated by Larson (1993), the costs associated with nursing care escalate substantially once pressure ulcers develop, with 50% more nursing time required to care for the patient. Iatrogenic ulcers have resulted in up to $92 million in malpractice awards (Larson, 1993).
The Joint Commission of Accreditation of Hospital Organizations (JCAHO) has established that pressure ulcers are an indicator of quality care (Larson, 1993). However, as explained by Larson, pressure ulcers must continue to be viewed within the context of the overall health of the patient. Pressure ulcers do not necessarily point to inferior quality-of-care, but rather to the complexity of the patient’s condition. While not all pressure ulcers are preventable or curable (Larson, 1993), accepting ownership of pressure ulcers places hospitals and nursing homes in jeopardy of punitive action from Medicare and state regulatory agencies. Lawsuits claiming personal injury negligence related to the development of pressure ulcers have significantly increased since the introduction of the Omnibus Budget Reconciliation Act of 1987. Between 1977 and 1997, the median settlement related to pressure ulcers in federal and state appellate cases was $250,000 (Bennett, O’Sullivan, Devito, & Remsburg, 2000).
The magnitude of the wound problem has been well documented. It is estimated that more than 5 million patients in the United States have chronic wounds (American Hospital Association, 2003), with 1.1 to 1.8 million people developing new pressure ulcers each year (Maklebust & Siggreen, 1991). The elderly and persons with spinal cord injury are two groups well-known to be at risk for pressure ulcer development (Young, Burns, Bowen & McCutchen, 1982; Stover & Fine, 1986; Allman, 1989). Data gathered on the prevalence of pressure ulcers have suggested a rate ranging from 4.7% (Allman, Larade & Noel, 1986) to 9.2% (Meehan, 1990), with other estimates suggesting a range of 3% to 14% in hospitalized patients to 25% in nursing home residents (Allman et al., 1986; Guralnik, Harris & White, 1988).
Pressure ulcers and other chronic wounds constitute an expensive and debilitating health care problem with significant clinical and social implications. These wounds are an expense to society in terms of money and human lives. Not only are pressure sores painful and a source for infection; they are also a marker for a greatly increased risk of death (Allman et al., 1986). Wounds resulting from skin breakdown also have great potential impact on a large number of quality-of-life issues, including life satisfaction, mental health, productive use of time, and caregiver burden. The emotional costs associated with the presence of a chronic wound compound the escalating financial burden of wound care for patients, families, and society.
Statement of Purpose
Evidence suggests that a number of factors are wound care management is becoming more complex for nurses due to new insights into wound healing (Hayward & Morrison, 1996) and because of the wide variety of wound dressings that are available (Wikblad & Anderson, 1995; Miller, 1994). Erwin-Toth and Hocevar (1995) stated that there were approximately 400 brands of wound care dressings on the market to choose from and that wound care is made even more difficult because no one dressing method suits all wounds and the choice is dependent on the cause of the wound, infection, favorability and cost (Findlay, 1994). Because of these many different wound care techniques and dressings, nurses are becoming confused and nonplussed regarding wound care practice. Unfortunately, Miller’s (1994) research showed that in 85% of cases nurses were using inappropriate dressings, and O’Connor (1993found in her study on wound care that nurses were having difficulty in applying their theory and knowledge to their practice.
On the basis of current problems associated with the complexity of wound care, the purpose of this thesis will be to explore current trends and practice recommendations in wound care. On the basis of the results of this exploration, a best nursing practices model in wound care will be developed.
Significance to Nursing basic philosophical premise associated with nursing in wound care is that which is focused on and advocates prevention and quick resolution of compromised skin integrity. Without a thorough understanding of the factors associated with effective wound care on the part of nurses, patients run the risk of skin break-down, further wound development, development of infections, long-term complications associated with wound healing, and the emergence of and ongoing presence of quality of life issues for patients. Therefore, efforts to provide nurses with information that is critical to the provision of effective care in relation to wound patients is significant for those engaged in nursing.
SECTION II: Integrated Review of the Literature
Within this section of the thesis, a literature review will be provided for the purposes of developing an understanding to the critical components and trends associated with wound care.
Wound Care Professionals
The results of a recent study by Bamberg, Sullivan and Conner-Kerr (2003) provide some indication of the types professionals providing wound care. The findings of this research suggest that the largest numbers of wound care service providers are registered nurses, followed by physical therapists, and thirdly followed by physicians. Most hold one or more national certification(s) related to wound care (i.e., CWOCN/CETN, CWS, or CNSWC), had completed a formal program of training in wound care (e.g., workshops, institutes, credit courses), and reported attending at least one continuing education workshop on wound care per year. According to Bamburg et al., most wound care specialists have a considerable experience base in wound care (mean = 10.9 years) with a mean of 64.1% of their professional work time being spent in wound care. This professional profile was similar across geographical regions within the U.S.
As reported by Bamberg et al. (2003), many wound care professionals work in more than one setting where they performed wound care. The most common work settings include acute care hospitals, followed by outpatient wound care centers where professionals work either full or part time. Most physicians and podiatrists provide wound care service in private practice as a work setting, though a few nurse practitioners have been identified as reporting this setting for their services. The vast majority of wound care professionals have indicated that Medicare and Medicaid patients. As well, patients also include those in health maintenance organizations (HMO) and as well as those that have private insurance. Similarly, many patients also represent those who self-pay.
Changes in Wound Management
As described by Hall and Schumann (2001), wound care is often a ritualistic procedure, resulting from social rather than wound factors. Hall and Schumann explained that there has been an ongoing revolution in wound care treatment that has taken place in the past 20 years that has demonstrated the expertise needed to provide quality care. Where once heat lamps, acetic acid, hydrogen peroxide, sugar and Maalox (TM), betadine packing, and dry wound healing were the protocols for care, wound care treatment has increasingly become more complex, with ever emerging standards-of-care for wound management. As others have noted (e.g., Skewes, 1996; Bruck, 1995; Nix, 2000), there is an ongoing recognition to the fact that what is put in, around, or on a wound can have a significant effect on healing, pain, scarring, infection, and debridement.
According to Hall and Schumann (2001), currently wound management products include everything from the basic adhesive strip and gauze squares to biosynthetic dressings and skin substitutes. Hall and Schumann further explained that a technology revolution continues to influence new products and treatments. This ongoing revolution results in a persistent and diligent need to re-examine practices in wound management in a continuing manner. Currently, there are more than 2,000 wound care products and support surfaces available in the U.S. (Baharestani, 1999). In 1997, wound management in the U.S. was a $1.94 billion business and is expected to grow to $2.57 billion by the year 2002 (Anonymous, 1997).
Psychosocial Aspects of Wound Care
According to Beck (1993), in wound care, there is a need to focus on the physical, psychological, social, environmental and spiritual dimensions of patients needs in assessment, planning and delivery of care. However, nursing assessments and strategies have most frequently concentrated on the physical aspects of wound management (Hopkins 2001). According to some (e.g., Beck, 1993;Teare & Barrett, 2002), holistic practice incorporating associated factors, such as pain, mobility and activities of daily living, falls mainly into the physical dimension, although there might be some acknowledgement of social influences. Most typically, patients who experience critical injuries and patients whose body image are threatened are more likely to be considered by nurses as requiring psychological and support (Salvador-Sasz,1999; Thelan, Davis, Urden, & Lough, 1994).
According to Newell (2000), considerations for the social and psychological tend to be offered only when body image is threatened by major, rather than minor, injuries, with facial disfigurement, loss of limbs or stoma formation rating most highly. However, even minor wounds may influence body image, as suggested by Price (2000), who indicated that body image is influenced by physical perceptions of the body to psychological experience through three basic components: body reality, body ideal and body presentation. As explained by Teare and Barnett (2002), on the basis of this model, patients who have wounds might experience changes in their body reality due to the physical nature of the wound. This has an impact on their perception of their body ideal, but might be linked to wider societal views of normal bodies. Body presentation is linked to physical appearance, but influenced by the environment, social support and personal coping strategies, and contributes with the other components to an overall construction of self-image.
According to Newell (2000), little effort has been made to examine patients whose physical appearance has changed, their adjustment to change, or their attempts to address these difficulties. As well, there is little documentation to suggest that nurses give extensive consideration to the effect of wounds on patients’ perception of their body.
According to Teare and Barrett (2002), nurses should consider the potential for loss of function and loss of status due to wounds both on a physical and social level. This will vary from individual to individual, depending on life circumstances. Teare and Barrett elaborated that for employed people it might affect their ability to work, whereas for retired people it can impinge on their social or caring activities. Ultimately, as noted by Teare and Barrett, how individuals feel about these changes is an important factor for self-esteem. Additionally, of further importance to nurses in the consideration of the social and psychological impact of wounds is that coping with treatment of wounds may lead to concerns about future alterations in lifestyle or anxiety about forthcoming nursing or medical procedures. According to Dewar and Morse (1995), often patients experience a wide range of emotional responses to ongoing hospital treatment that tests their ability to endure illness. Frequently, unbearable symptoms, such as pain, or intolerable treatments, results in patients feeling as thought they have reaching the limits of their ability to continue coping, resulting in behavior demonstrating frustration, irritation or anger (Dewar and Morse, 1995).
As well, as noted by Teare and Barrett (2002), patients may be influenced by the reactions of others or fears about reactions from others. According to the authors, research has documented that women react more and are concerned more about the possible reactions of others. Consequently, women have been found to experience poorer quality of life with similar wounds to men, with conclusions made that women place more value on physical appearance and suffered more psychologically from stigma caused by the reactions of others to their burns. The range of emotional responses to wounds can, therefore, encompass anger, denial, guilt, aggression, depression, grief, anxiety, isolation and feelings of worthlessness (Hopkins 2001).
Accurate assessment has been identified as critical to all aspects of wound care.
As explained by Nelson and Dilloway (2002), the assessment should include but is not limited to the identification and treatment of primary illness and comorbidities, identification of wound etiology, identification and elimination of causative factors of tissue damage, correction of abnormal laboratory values that contribute to poor wound healing, and identification of disciplines that should be involved. As explained by the authors, while most institutions have their own documentation form for assessment, nursing staff should insure that a thorough wound assessment is conducted, including the following parameters:
location of wound type/etiology of wound onset of wound size of wound (length x width x depth)– usually documented in cm tissue loss (partial thickness or full thickness) stage (pressure ulcers only) tracts/undermining exudate (amount, type, color) odor wound bed (granular, slough, eschar) periwound skin wound pain current treatment
As further explained by Nelson and Dillaway (2002), assessment provides the basis for the establishment of treatment goals, with definitive diagnosis of the wound preceding treatment. While, most often the expected outcome for the wound is healing, according to Nelson and Dillaway, depending on the medical situation, the goal might be delayed wound healing, or, in the case of the patient who is terminally ill or who has a chronic stable wound, the goal might be prevention of infection, maintenance, and symptom control. As noted by the authors, nurses are responsible for ongoing reassessment of the patient’s condition with the results of the assessment as it relates to wound progression altering the goal of wound treatment. A comprehensive multidisciplinary plan should be implemented.
As evidenced within the literature, there is an extensive body of nursing information available on assessment and treatment of wounds that concentrates predominantly on physical aspects of wound care. Miller and Collier (1996) provide an overview of wound healing linked to assessment and treatment while Dealey (1994) offers a comprehensive guide to management of wounds, and Morison et al. (1997) consider chronic wound management from a practical, evidence-based nursing viewpoint. Information is also available on ther specific physical factors that are considered linked to wound assessment, including pain assessment (Collier and Hollinworth,2000, Gould, 1999, Hollingworth 2001) and nutritional assessment (McLaren, 1997; Casey, 1998), which may highlight a possible cause of delayed healing.
Risk Factors Associated with Wound Healing
As identified within the literature, it appears that there are three major factors that have been found to influence failure of wound healing in chronic wounds. These factors include conditions related to the patient’s medical and physical status, conditions related to an environmental source, and iatrogenic causes related to specific wound care management techniques and/or products (Sussman, 1998). Other factors that may create risks in wound care include false reliance on mechanical devices without providing basic skin care, prolonged operative procedures, and delayed arrival at a health care facility after injury (Baharestani, 1999). As further explained by Sussman, other factors can assume a major role in facilitating wound healing including adequate staffing for patient care needs, adequate knowledge of wound care, frequent turning and repositioning with special attention to skin integrity over bony prominences, and adequate monitoring of skin integrity.
As identified by Sussman (1998), malnutrition has also been determined to influence inadequate wound healing. Thus, adequate nutrition and hydration are necessary for all steps of wound healing. The severity or stage of wound healing directly correlates with the severity of malnutrition (Sussman, 1998). On the basis of information provided by USDHHS (1994), malnutrition can be clinically diagnosed if 1) the serum albumin is less than 3.5 mg/dL, 2) the total lymphocyte count is less than 1,800/mm^sup 3^, or 3) body weight has decreased more than 15%. As explained by Sussman (1998), a patient’s protein and calorie needs are largely dependent on the size of the wound. These needs can vary from 2,000 calories for a small wound to 5,000 (or more) calories for a burn or multiple wounds. On the basis of information provided by USDHHS, supplemental intake may be necessary if oral intake is inadequate and parenteral nutrition may be utilized if the gut is not functioning efficiently. As well, according to USDHHS, vitamin C, zinc, and iron may assist in wound healing. A daily high-potency vitamin and mineral supplement is also recommended.
When wound care patients represent the elderly, as evidenced within the literature, there is vital need to consider nutrition issues. As explained by Zulkowski (2000), malnutrition affects 52% to 85% of institutionalized elderly and more than 55% of hospitalized elderly. Therefore, it is critical for nurses to consider, assess and determine the nutrition needs of elderly patients suffering from wounds.
According to Campton-Johnston and Wilson (2001), wound infection represents a significant problem, particularly with those who are suffering from complicated critical illnesses. As noted by the authors, wound infection delays wound closure; disrupts wound tensile strength; increases hospital length of stay and cost; and increases the patient’s risk of bacteremia, sepsis, multisystem organ failure, and death. Nurses are thus faced with aiding in insuring that the potential and occurrence for infection is reduced prior to the development of major difficulties. As explained by Campton-Johnston and Wilson, it is important to utilize universal precautions and/or isolation measures when resistant organisms are identified, as this represents the first line of defense in reducing the spread of infection. It is also important, as noted by the authors, that nurses be able to identify both the classic and not-so-obvious indicators and symptoms associated with wound infection. Nurses must also have knowledge and skill in correctly collecting a wound specimen, and be able to aid in the provision of appropriate systemic and topical wound management. According to Campton-Johnston, knowledge of the phases of wound healing represents another important area in dealing with wound infection as it provides a means for interpreting wound progress. As the authors explained, while all health care workers express a commitment to aid in the prevention of wound infections, prevention of wound infection is only possible through the provision of scrupulous wound care.
SECTION III: Method
The research methods selected for implementation within this thesis were based on the overall purpose of the study: to explore current trends and practice recommendations in wound care for the purposes of developing a nursing best practices model in wound care. A brief overview of the research design utilized within the study as well as the research procedures employed will be provided.
The research design selected for utilization in the study is one that allows for both the qualitative and quantitative exploration and analysis of information. This research design is that which is known as historiography, which provides a systematic process of the study of prior historical research (Schumacher & McMillan, 1993). While there is no single or unique definable description of historiography, as described by Schumacher and McMillan, the steps involved in conducting historical research are essentially the same as those in other types of research. The first step implemented within historical research is that which involves the identification of a research problem, topic, or subject, followed by the formulation of significant questions to be addressed. Historical records are then used as secondary data sources to systematically collect, evaluate and synthesize the source materials for the purpose of addressing the research question(s) under investigation.
As explained by Schumacher and McMillan (1993), in order to objectively evaluate the data obtained, both internal and external criteria are applied to establish the validity, credibility, and usefulness of source materials. The application of external criteria helps establish validity while application of internal criteria helps establish meaning. As explained by Schumacher and McMillan, the final steps of historical research include analyzing and interpreting evidence from each source, synthesizing information from the various sources, making generalizations, formulating conclusions, and confirming or disconfirming hypotheses, if hypotheses testing is included within the research plan.
For the purposes of the study, it was decided that the external criteria guiding the examination of historical records would include the following:
Only research studies found in historical records, including journals, periodicals and reports from reliable organizations conducted within the last 25 years would be included for analysis within the study.
Only research studies found in historical records, including journals, periodicals and reports from reliable organizations that examined the best practices in wound care would be included within the study.
It was also determined that the internal criteria to be applied within the study would include the following:
When examining historical records selected for inclusion within the study, the researcher would maintain objectivity and report any negative outcomes as well as positive found within the research reviewed.
The researcher would adhere to exploring only information of relevance to wound care and nursing best practices and would not include other information found within the studies selected for examination to insure that the focus of the study remained on target throughout the data collection and analysis process.
SECTION IV: Results
After having engaged in an effort to examine and analyze current articles and information available on wound care of relevant to establishing a model for nursing best practices in wound care, it was determined that this model would consist of the following: implementation of the basics, facilitating optimization of wound healing and implementation and maintenance of an ongoing plan for education.
Implementation of the Basics
The basics associated with wound care include the utilization of and initiation of a multi-disciplinary approach that recognizes and responds to the needs of the patient in a holistic manner. On the basis of the literature, it is evident that there is a critical need for the nurse as well as the other members of the team to conduct a comprehensive assessment of the physical as well as the social, psychological and environmental needs of the patient. The assessment developed provides the basis for the creation of a comprehensive plan for treatment and prevention. Regardless of what other goals and projected outcomes for healing may be established within the treatment plan, it remains critical for nurses to thoroughly inspect the wound daily, while evaluating issues related to adequate circulation, infection, nutrients and the need for debridement. Once adequate healing has taken place, the process must be reviewed to maintain the patient in a wound free state.
While numerous recommendations exist within the literature regarding what constitutes a comprehensive nursing assessment, the following basic guidelines should be followed in assessing the needs of wound care patient. The assessment should include
1) a complete history and physical examination, 2) the identification of complications and comorbid conditions, 3) a nutritional assessment, 4) a pain assessment, 5) a psychosocial assessment, and 6) an evaluation of the individual’s risks for the development of additional wound complications.
As suggested by Davidson (2002), when implementing assessment of the wound, it helps to keep in mind “the big picture,” focusing on location, shape, and size, particularly in relation to elderly patients with wounds. Recommendations regarding each of these were made by Davidson and are as follows:
Location. This can provide clues to the cause. For example, a trochanteric wound (on the bony prominence at the upper end of the femur) indicates pressure from a side-lying position, and an ischial wound (on the lower portion of the hip bone) indicates pressure from sitting. A sacral wound may be the result of sitting if the patient is elderly or has a weakened musculoskeletal system that causes him to slide down when he sits, applying pressure on his sacrum. As has been recommended, whenever possible, use anatomic landmarks and language to document the location of a wound. Left trochanter is preferred to left hip, and right medial malleolus is preferred to right inner ankle. A body diagram with separate views of the feet is useful to document wound location.
Shape. Wound shape also can shed light on the cause. A triangular sacral or coccygeal wound could be due to shearing and pressure forces caused by movement in bed. A linear wound on the posterior midthigh of someone who uses a wheelchair could be caused by pressure from the edge of the seat.
Size. Measure the length, width, and depth of a patient’s wound in centimeters. If possible, the same nurse should measure the wound and the patient should be in the same position for each subsequent assessment. Length is the largest area from a head-to-toe perspective; width, the largest area from a side-to- side perspective. When a wound has an irregular shape, a tracing is useful to document size. Use manufactured tracing sheets or a sheet of plastic wrap folded in half. Place it against the wound and trace around the perimeter. Remove the sheet, cut it along the fold, and place the half that touched the wound in a biohazard container. The part with the tracing is clean and can be included in the medical record. If a wound is photographed, it is important to insure that patient consent is obtained. Use wound film with size markings included or place a ruler in the photograph for perspective. To measure wound depth, moisten a sterile, cotton– tipped applicator with 0.9% sodium chloride solution. (Don’t use a dry one, which could injure newly formed granulation tissue.) Place the applicator tip in the deepest aspect of the wound and measure the distance to the skin level. If the depth is uneven, measure several areas; document the range and which part of the wound is the deepest.
As also emphasized by Davidson (2002), the descriptions of the wound provided by the nurse is also critically important. Davidson indicated that wounds are described as either partial or full thickness. According to Davidson, a partial-thickness wound consists of tissue damage to the epidermis and dermis while a full-thickness wound involves damage to the subcutaneous tissue, muscle, and bone.
Other recommendations provided by Davidson (2002), offer further guidelines for assessment best practices in reporting and describing general wound characteristics. As noted by Davidson, it is important to examine what’s in and around the wound to further assess it. Davidson recommended examination of the following:
Type of tissue. As described by Davidson, while a healthy fully granulating wound bed presents the best basis for healing, wounds can consist of varying amounts of healthy granulation tissue and nonviable tissue, such as slough or eschar. As delineated by Davidson, granulation tissue includes new blood vessels and immature collagen, initially pink and turning beefy red as it accumulates. Slough is moist, devitalized tissue that may adhere strongly or loosely to the wound bed and walls, ranging in color from yellow to tan. Eschar is dry, dead tissue that’s dark brown or black. According to Davidson, as tissue damage continues, eschar usually thickens and attaches more firmly to the wound. As emphasized by Davison, as the nurse identifies the types of tissue in the wound bed, it is important to estimate how much of each is present, such as 60% granulation, 20% slough, and 20% eschar. The percentages should be documented on a flow chart to permit the ongoing assessment of wound healing or deterioration.
Wound integrity. According to Davidson, if a fullthickness wound is determined, the nurse should assess for undermining and tunneling. Undermining consists of a hollow between the skin surface and the wound bed that occurs when necrosis destroys the underlying tissue while tunneling is a passageway within and beyond the wound walls or base. In order to document undermining or tunneling, as recommended by Davidson, relate its location to a clock, with 12 o’clock toward the patients head. An example of this technique includes the following: “Undermining of 4 cm from the 2 o’clock to the 6 o’clock position” or “The wound tunnels 6 cm at the 5 o’clock position.” The wound should also be examined for the presence of supporting structures, including tendons or bones. The nurse should note any orthopedic hardware as well as to remain alert for foreign bodies, such as structures and staples, all of which can increase infection.
Exudate. As recommended by Davidson, the nurse should follow their facility’s guidelines for defining “small,” “moderate,” and “high” amounts. Describe the exudate as serous, serosanguineous, or purulent. Infection can affect the color, consistency, and amount of exudate as well as cause an odor.
Wound edges. According to Davidson, in full-thickness wounds, particularly when undermining is present, the edges may curl under and delay healing. As further clarified by Davidon, the nurse should recognize a white, shiny appearance at the wound edges as signaling healing, resulting from the migration of the epidermal cells across the wound to resurface it.
Periwound skin. As indicated by Davidson, the skin around the wound should be assessed for color, moisture, intactness, induration, edema, pain, and presence of a rash, trophic skin changes, and infection. The skin color may be pink, red, blue, pale white, or gray; in darker skin, deeper skin tones may be noted. Pink usually indicates healthy skin; red may indicate friction, pressure, or beginning infection; blue or pale white is often a sign of compromised circulation. Erythema may or may not blanch when pressure is applied. As well, there may be too much moisture apparent in the skin around the wound, increasing the risk for fungal or yeast infection. Concern also has to be directed towards the presence of primary skin lesions as well as the presence of a hyperkeratotic rim, which is, as Davidson described, often associated with neuropathic wounds on a weight-bearing surface. According to Davidson, infection of the periwound tissue often presents with erythema; induration; warmth; change in the color, odor, or consistency of the exudate; and pain.
Davidson (2002) stressed the importance of documentation and the inclusion of a wound assessment within the larger comprehensive assessment. Recommendations for documentation also included the use of a flow sheet as well as narrative notes. Equally important is the communication of the results of the wound assessment in order to guide treatment goals as well as monitoring purposes.
Optimization of Wound Healing
As documented within current information, the most important goal associated with wound care is wound healing. Nurses who assume a holistic approach to wound care recognize that the basis of optimizing wound healing is found in aiding and facilitating healing by helping the body to heal itself. As identified within the literature, (Hall & Schumann, 2001), appropriate wound dressing is crucial to the process. Information provided by Hall and Schumann on wound dressings is useful in establishing a basis for best practices in this aspect of wound care. According to Hall and Schumann, there are many types of wound dressings, including transparent films, foams, hydrocolloids, hydrogels, and alginates. Due to the variety of wound dressings that are available, it may be difficult for the nurse to determine the most appropriate dressing. Nurses must be guided in selection by evaluating potential dressings on the basis of a model for determining the most ideal addressing.
According to Hall and Schumann (2001), an ideal dressing is one that allows for keeping the wound moist while keeping the surrounding intact skin dry. As explained by Hall and Schumann, moisture has been found to influence subsequent comfort, faster healing, autolytic debridement, and fewer infections in comparison to dry wounds. On the other hand, it is important for nurses to realize that prolonged exposure to excessive wound exudates can lead to increased risks associated with maceration of the surrounding tissue.
Determining an ideal dressing for a specific patient requires that the nurse recognizes and uses an approach that focuses on individualization of wound care. In relation to each wound care patient, it is necessary for the nurse to conduct an assessment of the wound, assessment of the patient’s lifestyle, and determination of where the wound will be managed (home, hospital or extended care facility), and by whom (Hall & Schumann, 2001). Whether or not the hospital has a list of recommended wound care products and guidelines for their use does not negate the health care provider’s responsibility for selecting the correct dressing. Before using any wound care product for the first time, always consult the manufacturer’s recommendations, contraindications, precautions and warnings.
According to Hall and Schumann (2001), the use of dry, sterile gauze dressings continues to represent the “gold standard” of treatment for wound management within the U.S., used for approximately 70% of wounds. However, as noted by Hall and Schumann, prior research does not support the degree to which this type of dressing is used. Evidence suggests that when comparing the cost of saline soaked gauze and the time spent on dressing changes with the cost of treatment with hydrocolloids, the charges for the saline soaked gauze regimen were four times as expensive as the hydrocolloids. Other complications identified in relation to the use of gauze include: gauze tends to shed easily, which leads to contamination of the wound; gauze dressings dry the surface of the wound; removal of the gauze dressing further traumatizes and damages granulation tissue and leads to increased pain, increased bacterial permeability, and an environment for further bacterial growth. In the managed care environment, with greater attention to cost-benefit analysis, the use of gauze is expected to decline and the use of advanced wound care products to increase. Table 1 provides principles associated with ideal wound dressings as described by Hall and Schumann (2001). These principles can be followed in determining and establishing best practices in nursing in optimizing healing.
Table 1: Ideal Dressing
Removes exudate but does not allow the wound to dry
Impermeable to microorganisms
Allows gaseous exchange of oxygen, water vapor, and Free from particulate or toxic contamination carbon dioxide
Thermally insulates to maintain a core temperature of Nontraumatic to the wound
37 degrees C
Availability of outcome data from the manufacturer, well Provides a healing environment that is controlled studies preferred over patient testimonials. compatible with the wound and overall treatment goals for the patient and family
Easy to apply and remove and easy to follow directions Remains in place for an acceptable amount
For application by patient or family member time
Simplified treatment with minimal dressing change and Cost effective, reimbursable expense or minimal need for secondary dressing affordable for the patient
Easily obtainable Acceptable for use with infected wounds
In Table 2, principles of wound dressings as identified by Hall and Schumann (2001) are outlined and can be used to establish best practices in optimizing in wound healing by nurses.
Table 2: Principles of Wound Dressings
1. Categorization The health care provider needs to learn about dressings by generic category and compare each product in that category.
2. Selection Select the safest, most effective user friendly and cost effective dressing as possible.
3. Change the dressing on the patient’s wound and dressing assessment rather than on the basis of standardized routines.
4. Evolution As the wound moves through phases of healing, the health care provider needs to evolve the dressing protocol in order to optimize healing.
5. Practice with dressing materials to learn their performance parameters and related tricks of the trade.
Wound cleansing has also been identified as critical for optimizing wound healing. Selecting an appropriate wound cleanser is as important as wound dressing selection. According to Hall and Schumann (2001), an easy rule of thumb for cleansing a wound is “don’t put in a wound what you wouldn’t put in your eye.” Normal saline has been identified as the preferred cleansing agent as it will not harm the tissue while providing adequate cleaning. Other guidelines associated with the use of wound care cleansers include the need for most wound cleansers to be diluted to maintain white blood cell viability and phagocyte function.
The Importance of Education
As is evidenced within the literature, education is one of the most critical factors impacting the clinician’s knowledge and competence in wound care management. However, as some have suggested, when reviewing medical-surgical textbooks, most only provide a brief description of wound care and prevention of infection, leaving an incomplete and sometimes inaccurate analysis of wound care. As Olshansky (1994) noted, overall while assessing the patient’s risk factors in wound healing is important, it is equally, if not more important to assess the nurse’s skill in providing wound care as well as their knowledge about wound prevention skills. r’s ability to provide wound care and knowledge about wound prevention skills. Olshansky, 1994). Studies have shown that caregiver expertise or level of wound care knowledge can have a direct effect on the healing outcome (Arnold, & Weir, 1994). As recommended by Hall and Schumann (2001), healthcare professionals must be able to understand, assess and compare all aspects of wound care management. On the basis of this analysis, nurses are expected to then be able to recommend wound care practice strategies that are empirically based.
While information technology has brought with it the massive transmission of knowledge as well as the tools by which such information can be readily accessed, nurses frequently find themselves challenged by the demands associated with keeping up with the growing knowledge base on wound care. Patient care in itself is time consuming and demanding as are the responsibilities associated with charting and the other demands associated with maintaining one’s licenses and credentials. The costs associated with subscriptions to journals or trips to the library also present unique challenges to nurses who value and want to stay up-to-date with current information in their specialty areas or areas of interest. However, education remains a critical key in insuring wound healing and effective wound care. Nurses ultimately are responsible for insuring that they develop educational plans and strategies for staying up-to-date on current knowledge emerging about wound care. The reality is that information can become quickly outdated and what is new today may very well be headed for extinction within a short period of time. Nurses find themselves challenged by this ongoing and ever-changing influx of new and complex information on wound care. In spite of these difficulties, nurses must engage in the consistent battle to continue in their efforts to obtain the information needed to provide quality and effective wound care.
SECTION V: Conclusions
Within the thesis, an overview of issues associated with appropriate wound care was provided. The purpose of the thesis was to further examine and explore current trends and practice recommendations in wound care for the purposes of developing a nursing best practices model in wound care. The literature was reviewed and examined in order to determine principles associated with a model of in which recommendations concerning basic practices recognized as critical to wound care and healing. This model was outlined in Section 4, with attention directed towards implementation of the basics, facilitating optimization of wound healing and implementation and maintenance of an ongoing plan for education. The model will hopefully have utility to nurses in their efforts to deal with the complexities associated with wound care by offering a framework which they can use to organize their practice on the basis of a foundation focused on insuring that the basics of wound care are attended to in order to insure wound healing.
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