Wound Care

CLINICAL GUIDELINES

A healthcare prescriber orders wound care. Optimally, specific written directions are given for the type of cleansing solution, topical antimicrobial or antiseptic agent, dressing material, and the frequency of the dressing changes.
Wound care is performed by a registered nurse (RN), licensed practical nurse (LPN), healthcare prescriber, or a family member who has been taught techniques of wound management and dressing change for the child.
A head-to-toe skin assessment of the child is completed on admission. Thereafter, the skin is assessed on a regularly scheduled basis or when there is a significant change in the child’s condition to determine signs that may indicate risk for compromised skin integrity and to assess known areas of skin breakdown and visible wounds.
Use of a valid and reliable risk assessment tools/scales are employed per institutional policy (e.g., Braden Q Scale).
The child receives topical wound therapy that supports a moist, healing environment and minimizes the risk for complications. Wound therapy includes dressing materials, wound-cleansing solutions, wound-cleansing technique, topical medications, methods to secure the dressing, and support surfaces that redistribute pressure such as specialty beds, mattress overlays, and seating surfaces.
The child receives or maintains appropriate medical care to promote wound healing and to minimize the risk for complications. This includes nutrition, fluids, oxygenation, circulation, and systemic medications.
The child receives interventions to reduce or eliminate causative factors in wound formation, such as excessive moisture, pressure, shear, and friction, as well as interventions to minimize the deleterious effects of immobility, neuropathy, paralysis, impaired circulation, and impaired oxygenation. If the wound is a result of pressure, keep pressure off this area even if a support surface is used.
Use the Aseptic Non-Touch Technique (ANTT) risk assessment to determine the selection of Standard-ANTT or Surgical-ANTT. That is, does the technical difficulty of the procedure require the Key-Parts and Key-Sites to be touched directly? If yes, use sterile gloves and Surgical-ANTT. If no, Standard-ANTT is used to perform wound care (Figure 125-1).
Any wound with signs and/or symptoms of infection should be cultured.
Pharmacologic and biobehavioral measures are used before and during wound care procedures to minimize child’s discomfort during the procedure (see Chapter 7).

EQUIPMENT

Sterile or nonsterile gloves and the type of aseptic fields utilized is dependent on the selection of Standard-ANTT or Surgical-ANTT (Figure 125-1).
Personal protective equipment
Optional to facilitate adhesive/tape removal:
- Cotton balls
- Water
- Mineral oil or petrolatum (optional)
Wound-cleansing solution
Wound-cleansing delivery method such as cottontipped applicators, gauze or 35-mL syringe, and 19-gauge Teflon catheter for irrigation
Topical antimicrobial or antiseptic (if ordered)
Dressing materials (primary dressing; secondary dressing if necessary)
Material to secure dressing such as tape, Montgomery straps, stretch net tubular elastic dressing, or bandage
Biohazard bag (as needed)
Waste Receptacle

CHILD AND FAMILY ASSESSMENT AND PREPARATION

Assess pertinent history, focusing on primary reason child has a wound (e.g., surgical incision, intravascular access site, pressure ulcer, accidental injury) and the plan for wound care at home, if appropriate.

Figure 125-1 Aseptic Non-Touch Technique Approach. Used with permission of The Association for Safe Aseptic Practice/www.antt.org
Assess medical record and double-check with the patient and caregiver for the presence of any allergies, including those to latex, tape or adhesives, and any skincare products that would affect wound care.
Describe the wound care procedure to the child and the family. Collaborate with them in identifying a time during the day for the dressing change(s) allowing premedication of analgesics if appropriate.
Assess the child’s developmental level and understanding of the wound care/dressing change process.
Utilize dolls or models to demonstrate the care, if appropriate, or assist the child to identify ways he or she can help with the dressing change (e.g., remove tape, help lift off the dressing, help gather dressing supplies, etc.).
Assess the child’s and the family’s ability and readiness to participate in the wound care and dressing change.
Assess the child’s pain level with each dressing change and deliver appropriate pain relief interventions before initiating wound care. Assess the effectiveness of distraction and comfort measures used with dressing changes.
Determine whether dressing change should be performed in the treatment room to ensure that the child’s bed and/or room remains a “safe location” free from painful experiences.

PROCEDURE
Providing Wound Care

Steps	Rationale/Points of Emphasis
1 Perform hand hygiene using either liquid gel or soap and water before entering a patient zone.	World Health Organization recognizes hand hygiene should be completed before patient contact as the first of five key moments when hand hygiene should be completed.
2 Prepare the child and family for the procedure.	Helps to ensure child and family cooperation, and participation as needed in the performance of the procedure.
3 Raise the bed and place the child in a position of comfort so that the wound site can be easily reached during wound care. Protect the child’s privacy by keeping other body parts well covered.	Promotes good body mechanics.
4 Perform the ANTT Risk Assessment to determine a Standard-ANTT or Surgical-ANTT (Figure 125-1 ).	If the procedure is technically simple enough not to have to touch the Key-Parts directly, use Standard-ANTT. If no, then use Surgical-ANTT.
5 Perform hand hygiene.	A key moment for hand hygiene is before completing an aseptic task.
6 Decontaminate and disinfect procedure tray/trolley/surface to create a “general aseptic field.”	The field promotes asepsis and dictates how equipment will be managed by the healthcare provider.
7 Gather the necessary supplies.	Promotes efficient time management and provides an organized approach to the procedure.
8 Perform hand hygiene and don nonsterile or sterile gloves and personal protective equipment based on the ANTT Approach (Figure 125-1 ).	Standard precautions to reduce transmission of microorganisms.
9 Assemble equipment protecting Key-Parts using a Non-Touch Technique.	Prevents contamination of equipment.
10a Carefully remove old dressing. It may be necessary to use water to loosen dressing. For the neonate, remove the dressing and any adhesives slowly and carefully using sterile water-soaked cotton balls. Pull tape on a horizontal plane, folding tape back onto itself while continuously wetting the adhesive-skin interface. Alternatively, use mineral oil or petrolatum to loosen tape unless retaping is necessary at that site.	Applying water helps loosen the dressing and therefore decreases pain of removal as well as trauma to the skin and the wound. Adhesive removal from the skin of the premature infant has been documented to cause epidermal detachment. Measures must be used to minimize the trauma from adhesive removal (Chart 125-1 ).
10b Inspect the old dressing. The dressing tells a story of the wound’s progress and amount of drainage and odor.	Sometimes the dressings themselves breakdown in a wound and these dressings may have an odor or have a specific drainage so that it may not represent the wound.
10c Dispose of old dressing in trash receptacle. Use a biohazard bag if needed to designate medical waste that contains significant amounts of blood or other body fluids.	Biohazard bags are an essential item to control the spread of diseases from human waste, discarded medical supplies, and biologic contaminates. The red bags are marked with the international symbol to alert others of the hazardous waste contained within to ensure proper handling.
11 Remove gloves, clean hands, and re-glove.	Reduces transmission of microorganisms.
12 Cleanse wound bed and the surrounding skin with appropriate solution. Clean using moist cottontipped applicators or gauze pads, moving from clean area to dirty area.	Normal saline, tap water, and commercially prepared wound-cleansing solutions are recommended for cleansing. The use of tap water is not associated with the development of wound infection. However, the quality of the tap water should be considered before its use. In the absence of potable (drinkable) tap water, boiled and cooled water as well as distilled water can be used as wound-cleansing agents.
If the wound exhibits signs of infection such as purulent or increased drainage, odor or warmth, swelling, increased redness, and/or tenderness of the periwound tissue, the wound bed should be cultured. Cleanse the wound surface well with water or normal saline before culture is obtained.	caREminder
Antiseptic solutions such as povidoneiodine, Dakin’s solution, and hydrogen peroxide should be used with caution if at all. They are cytotoxic to healing tissue and nonselectively debride healthy tissue as well as necrotic tissue. The prescriber may order their occasional use at a weak dilution for a nonhealing wound.	Wounds with large amount of debris may benefit from syringe irrigation. In the home setting, rinsing under a running faucet or hand-held shower sprayer are acceptable methods of cleansing the wound surface. In school settings, liquid antibacterial soap and tap water are used for wound care unless there is a full-thickness injury involving tendons, blood vessels, and/or bones.
For the preterm or term infant, percutaneous absorption of topically applied substances and the potential for drug toxicities is of great concern because of the immaturity of the epidermal permeability barrier that can result in increased absorption. Topical agents such as isopropyl alcohol and povidone-iodine should not be used in preterm or term infant wound care.	For neonates, sterile water or normal saline diluted 1:1 with sterile water warmed to body temperature is preferred for cleansing.
13 Inspect the wound bed and document findings with attention to size, tissue type and color of tissue in wound base, wound edges, exudates (color and amount), odor, condition of surrounding tissue, and pain.	Measure length, width, depth, and for the presence or absence of undermining and tunneling. Viable granulation tissue is red, glistens, and bleeds easily due to its vascular makeup. Tough yellow tissue is nonviable slough and must be debrided. Dark-brown, black, necrotic, or leathery tissue is nonviable and must be debrided. All nonviable tissue is a foreign body that impedes wound healing. Serous and serosanguineous drainage are normal. Purulent drainage is abnormal. Wounds heal from the outer edges to center and from wound base to top. New skin is first evident on wound borders as pink epithelialization.
caREminder
Always clean the wound before you finalize your wound assessment.
14 Apply topical medication if ordered.	Topical medication requires contact with wound surface to be effective. Amorphous hydrogel can be applied without a physicians order and aids in wound moisturizing and healing for wounds that are dry. Use topical antimicrobials in the wound bed cautiously; their use has been associated with the potential for transdermal absorption (e.g., silver sulfadiazine in neonates) and the development of contact sensitivity.
15 Apply primary dressing to wound surface only.	Maintain moist wound surface to promote healing, but keep moist dressing off surrounding skin to prevent maceration. There is overwhelming support of maintaining a moist wound surface to promote wound healing. A moist surface permits faster and more efficient migration of tissue cells (vascular, collagen, and epithelial), enhances nutrient delivery, and facilitates waste removal (dead cells and secretions). It is important to match wound characteristics with dressing features to obtain the desired outcome.
caREminder
Wound healing is optimized in a moist environment that is created by dressings such as hydrocolloids, hydrogels, hydrofibers, foams, films, alginates, collagens, or soft silicones as opposed to basic dressings such as gauze, vaseline gauze, and simple dressing pads.
16 Apply secondary dressing if necessary.	Secondary dressings are absorptive and provide cover to the primary dressing.
17 Secure the dressing with tape, a semipermeable dressing, or Montgomery straps. A soft gauze or stretch net bandage can be used for extremities. For neonates, minimize contact between adhesive tape and skin by “backing” tape with tape or gauze.	Choose a method for securing the dressing that maintains integrity of the dressing, minimizes trauma to surrounding tissue, and is compatible with the dressing change frequency. Avoid adhesive methods when the dressing change frequency is greater than once a day. Montgomery straps can be made for younger children by using a small piece of pectin wafer, cloth tape, and tracheostomy ties. For older children and teens, consider using an alcohol-free “no sting” barrier wipe before applying tape to protect the skin from epidermal stripping and discomfort during tape removal.
18 Dispose of waste in appropriate receptacle. Return reusable supplies to secure location.	Reusable supplies, such as cleansing solutions, should be placed in a location out of the child’s reach to prevent potential injury.
19 Remove gloves and personal protective equipment and dispose of waste in appropriate receptacle. Return reusable supplies to safe storage area. Perform hand hygiene.	Reduces transmission of organisms.