49. Wound Care

There are three parts to this section:

1 Wound bed preparation

2 Wound drain care

3 Removal of stitches, clips and staples

The concluding subsection ‘Patient/carer education: key points’ and the ‘Self-assessment questions’ refer to the chapter collectively.

Learning outcomes

By the end of this section, you should know how to:

▪ assess the patient for these three nursing practices

▪ collect and prepare appropriate equipment

▪ carry out these nursing practices.

The concept of wound care is vast, with an ever-evolving knowledge base offering direction for best practice. This chapter therefore presents the basic knowledge required for these practices and encourages you to reflect on your own learning needs to develop a relevant knowledge base. References and useful web addresses are provided at the end of this chapter as a starting point for this process.

Background knowledge required

Revision of the physiology of wound healing and the factors that affect wound healing

Revision of the principles of wound assessment

Review of existing local policy and national guidelines regarding all three components of this chapter

Review of common wound dressings available and their individual properties (note: in hospitals, available dressings may vary depending on the stock held by pharmacy. In the community setting a wider selection is usually accessible).

1. WOUND BED PREPARATION

Indications and rationale for wound bed preparation

Wound bed preparation is a process that assists in optimising conditions at the wound bed to encourage healing (Shultz et al 2005). This process requires the nurse to have a basic knowledge of the physiology of the stages of wound healing as this will help to understand the reasons why some wounds fail to heal effectively and/or quickly.

The main aims of wound bed preparation are:

▪ to provide a method for continual assessment of the wound bed for tissue type

▪ to monitor and treat any signs/symptoms of critical colonisation/clinical infection appropriately

▪ to address any moisture imbalance evident in the wound bed by either rehydrating sloughy/necrotic tissue or removing excess volumes of exudate

▪ to monitor the edges of the wound for signs/symptoms of effective healing.

Assessment

The first step of wound bed preparation should involve a holistic assessment of the patient. Wound assessment tools are of value within this process as they provide prompting and direction for appropriate care (Hess & Kirsner 2003). The tool chosen should address both local and systemic factors that may impact on the ability of the patient to heal effectively (Hess & Kirsner 2003). Examples of local factors that may need to be addressed include pressure area assessments; continence assessments; and evidence of trauma. Examples of systemic factors include peripheral vascular disease; immunosuppression; and nutritional status. Once identified, action must be taken to rectify any unmet need that may delay effective wound healing, e.g.:

▪ use of specialist pressure reducing or continence equipment

▪ referral onto relevant members of the multi-disciplinary team.

Assessment tools also collect basic information such as the position and depth of the wound; the cause of the wound, e.g. trauma, surgical incision; how long the wound has been there; and any allergies the patient may have to previously tried dressings. The use of clinically assessed, research-based assessment tools not only offers direction for care but also a means of objective monitoring that can be used within clinical audit. Pressure ulcers can be graded by means of recognised classification scales, a process that will help in the accurate description of these wounds (DeFloor & Shoonhoven 2004).

A grid map can be used to assess the original size of a wound and consequent changes to size and tissue type on the wound bed. Care should be taken, however, that consensus is agreed within the clinical area in relation to the counting of the squares within the wound-bed area (Keast et al 2004). A camera may be used to record effectively both the size and tissue type of the wound bed, however this should be used in conjunction with local protocols to adhere to legal requirements including the Data Protection Act (Department of Health 1998). Again, knowledge of local guidelines and protocols should guide practice.

A Doppler ultrasound can also be used by skilled personnel in the assessment of leg ulcers to determine if they are vascular or arterial in nature. This is important as treatment will vary significantly depending on the result of this test. Vascular wounds will require referral to a vascular clinic for further assessment while venous leg ulcers are appropriate for compression bandaging. Compression bandaging must only be applied by staff who have received training in this practice as badly applied bandaging can cause damage to the lower limb.

Tissue type

There are five main types of tissue found in wounds, and a popular way to describe these types objectively is by colour (Hess & Kirsner 2003, Keast et al 2004, Shultz et al 2005):

▪ Black – necrotic

▪ Yellow – sloughy

▪ Green – infected

▪ Red – granulating

▪ Pink – epithelialising.

Infection

Wounds that are taking longer to heal than expected but do not appear clinically infected should be assessed for ‘critical colonisation’. This means that bacteria in the wound are of a great enough number to compete for existing nutrients and oxygen against healthy cells, but are not of a great enough number to cause a clinically infected wound (Warriner & Burrell 2005). Signs of critical colonisation include delayed healing, wound breakdown and discoloration of the granulation tissue from red to dusky red/purple.

Clinically infected wounds will require further assessment by medical staff to assess if an antibiotic is required. Critically colonised wounds will benefit from the use of dressings that contain broad-spectrum antimicrobial properties such as silver or iodine. It is important to note that these dressings are expensive and require frequent reassessment to ensure their effectiveness. Once healthy tissue is observed in the wound bed these dressings can be stopped and other dressings can be applied.

Moisture

Included should be an assessment of the volume, colour and viscosity of any exudate present. Too little exudate and a scab (eschar) will form, contraindicating the moist, warm environment required for effective wound healing. High volumes of exudate will impact on surrounding tissue, causing maceration and prevent the wound from progressing further. Dressings for necrotic (black)/sloughy (yellow) tissue with low volumes of exudates should be chosen to rehydrate the eschar/slough, e.g. hydrogels or hydrocolloids. Wounds with high volumes of exudate require dressings that will absorb the exudates effectively, e.g. foams or hydrofibres.

Wound edges

As stated above, excess volumes of exudates will have a detrimental effect on surrounding tissue. Assessment should also involve gentle probing of the wound margins to rule out undermining of tissue. In a healing wound the margins of the wound advance across the wound bed thereby leading to an epithelialised (pink) wound. If this process fails then reassessment is required to identify the failure of the process.

Wound cleansing

Once a routine procedure, it is important that the nurse questions the need for wound cleansing prior to each individual dressing change. Research shows (Barber 2002) that wound cleansing is only necessary under certain circumstances:

▪ when specifically indicated by the dressing manufacturer, e.g. hydrogels, alginates

▪ in traumatic wounds to assist in visualising the wound bed.

If cleansing is indicated, again informed decision making should direct the choice of fluid used. Tap water can be used to irrigate wounds with no greater incidence of wound infection when compared to normal saline (Fernandez et al 2002). However, risk assessment guidelines should be followed to ensure the quality of the water used (Barber 2002, Fernandez et al 2002). No other fluid, e.g. chlorhexidine/betadine should be used to cleanse a wound unless within a specific aseptic technique or if requested by a clinical specialist with research to support the request.

Reference should be made to the use of an aseptic technique within this discussion. Once a routine procedure, a risk assessment will direct the nurse in the appropriate decision as to whether this practice is necessary. For certain procedures, e.g. care of a Hickman line, an aseptic technique is vital to protect the patient from infection. However, in general, wounds will not require an aseptic technique, e.g. leg ulcers, pressure sores (Barber 2002).

Choosing a wound dressing

Nurses are accountable for administering topical preparations, as they are for the administration of all other medicines, so they must be familiar with the properties and side effects of any wound-care products they are using. Up-to-date information on these preparations is available from the British National Formulary (2005). Dressings should provide a moist, warm environment for optimum wound healing to occur. They should also:

▪ be impermeable to bacteria

▪ be non-toxic and non-allergenic

▪ be comfortable and conformable for the patient to wear

▪ protect the wound from further trauma

▪ require infrequent dressing changes

▪ be cost-effective

▪ have a long shelf life

▪ be available in both hospital and community settings.

In addition to the above, it is also important for the dressing to have the necessary physiological and biochemical properties to facilitate wound healing at a cellular level. Tissue Viability Nurse specialists offer a wealth of knowledge in wound healing and treatment options and are available in both acute and community settings to provide support for ‘difficult’ wounds.

Larval therapy also provides an option for the debridement of necrotic/sloughy wounds (MacDougall & Rodgers 2004). Available on prescription, the larvae ingest dead tissue without affecting healthy tissue and can also be used when a wound is infected, indeed research shows that they may be effective in eradicating MRSA from infected wounds (Thomas & Jones 2000).

Due to budgetary constraints, ward-based nurses may have a limited number of dressings available via pharmacy. Within the community most district nurses have undertaken a nationally accredited course to enable them to prescribe from a wide range of wound-care products. A nurse prescriber must maintain an awareness of recent research, ensuring that decision making is grounded in a balance of both cost effectiveness and the proven effectiveness of the dressing.

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Equipment required for a wound assessment and non-aseptic dressing change

1. Wound assessment tool

2. Grid/camera

3. Dressing pack/swabs (only if required)

4. Flat surface

5. Gloves/apron

6. Disposal bag

7. Water/normal saline (only if required)

8. Alcohol-based hand rub

9. Clean scissors (to cut tape or the dressing to fit the wound)

10. Appropriate dressings/securing bandage (if required).

For many dressings a dressing pack will not be required. Simple dressings will require removal of the old dressing and application of a new dressing. Since all dressings are packaged within a sterile field, careful removal of these dressings negates the need for any further sterile field to lay them on. In an institutional environment, the number of air-borne pathogenic micro-organisms can be reduced by working in a well-ventilated room used solely for procedures involving aseptic technique, or by performing procedures at least 30 minutes after the completion of ward cleaning and bed making. This may not always be possible in the home setting, where the community nurse has little control over the environment.

There is no need for the nurse to wear a disposable cap or face mask, but verbal communication should be kept to a minimum during the aseptic technique in order to reduce droplet contamination. When a number of aseptic wound dressings are to be performed, a known contaminated and/or infected wound should be treated last to reduce environmental contamination.

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Guidelines and rationale for a wound assessment and non-aseptic dressing change

▪ explain the nursing practice to the patient to gain consent and co-operation

▪ collect and prepare the equipment required to ensure that it is available and ready for use

▪ ensure the patient’s privacy to reduce anxiety

▪ help the patient into a comfortable position to create a sense of wellbeing

▪ place a drape/towel under the wound if possible to protect the bed/chair/floor from potential leakage of exudates and/or to protect from irrigation fluid (if used)

▪ wash hands and apply gloves/apron to reduce cross-infection (National Institute for Clinical Excellence 2003)

▪ remove any existing dressing to allow a clear assessment of the wound

▪ use an appropriate wound assessment tool to assess the patient and the wound bed thereby ensuring a holistic assessment of the patient

▪ assess and record the shape of the wound using a measured grid tracing or grid camera to permit changes to the wound shape to be noted. If a camera is used the appropriate paperwork must be completed to ensure both consent and legal ownership of the photos; knowledge of local guidelines and protocols should be used to guide best practice

▪ assess wound bed tissue; any evidence of infection; volume of exudates and wound edges exudate as this will assist with the decision-making process to determine the choice of dressing

▪ assess and document the wound bed tissue type to provide information regarding the stage of healing

▪ carry out a pain assessment to determine the analgesic requirement and the timing of any medication required

▪ discuss with the patient previous treatments and their effect, allergies and dressing preferences to increase concordance with the treatment regime

▪ decide on the most appropriate dressing for the presenting wound (if this has changed from the existing dressing, remove and dispose of gloves; collect new dressing; wash hands again and apply new gloves) to ensure effective treatment for the patient

▪ irrigate wound with either warm saline or tap water only if indicated to ensure that research-based practice is followed

▪ apply appropriate dressing

▪ following the initial assessment, evaluate the wound at regular intervals to monitor the overall progress of the wound

▪ ensure that the patient is left feeling as comfortable as possible, maintaining the quality of this nursing practice

▪ dispose of the equipment safely to reduce any health hazard

▪ document the nursing practice appropriately, monitor the after-effects and report any abnormal findings. This provides a written record and assists in the implementation of any action should an abnormality or adverse reaction to the practice be noted

▪ in undertaking this practice, nurses are accountable for their actions, the quality of care delivered and record-keeping according to the Code of Professional Conduct: Standards for Conduct, Performance and Ethics (Nursing and Midwifery Council 2004) and Guidelines for Records and Record Keeping (Nursing and Midwifery Council 2005).

Thorough handwashing prior to the dressing must be performed, further hand preparation being performed during the aseptic technique as stated in the guidelines above and whenever the nurse accidentally contaminates his or her hands. An alcohol-based hand rub is used for the subsequent hand preparation; it has the benefit that the nurse does not have to leave the patient during the practice (Jeanes 2005).

It is preferable for the skin-cleansing lotion to be supplied as an individual single-use sterile sachet or bottle. Once a bottle has been opened, environmental contamination can occur, so any residual lotion should be discarded. If an aerosol can of irrigating fluid is used, the nurse should ensure that the dispensing nozzle does not become contaminated and therefore act as a source of infection.