WOUND CARE
Description:
There are two ways that wounds heal: regeneration or scar formation. During regeneration,
tissue that has been damaged is replaced by tissue of the same type. This preserves the
proper function of the area of the body that has been injured. In scar formation, the damaged
tissue is replaced by fibrous scar tissue which doesn’t have the same properties as the
original tissue.
Proper wound care prevents infection and other complications, and also helps speed up the
healing process with less scarring.
Procedure:
1.Check present dressing with non-sterile gloves.
2. Perform hand hygiene.
3. Gather necessary equipment.
4. Prepare environment, position patient, adjust height of bed, turn on lights.
5. Perform hand hygiene.
6. Prepare sterile field.
7. Add necessary sterile supplies.
8. Pour cleansing solution.
9. Prepare patient and expose dressed wound.
10. Apply non-sterile gloves.
11. Remove outer dressing with non-sterile gloves and discard as per agency policy.
12. Remove inner dressing with transfer forceps, if necessary.
13. Discard transfer forceps and non-sterile gloves according to agency policy.
14. Assess wound.
15. Drape patient with water-resistant underpad (optional).
16. Apply non-sterile gloves (optional).
17. Cleanse wound using one 2 x 2 gauze per stroke.
18. Cleanse around drain (if present).
19. Apply inner dressing (4 x 4 gauze) with forceps to incision, then drain site (drain
sponges/cut gauze).
20. Discard non-sterile gloves if they were used.
21. Apply outer dressing, keeping the inside of the sterile dressing touching the wound.
22. To complete dressing change:
Assist patient to comfortable position.
Lower patient’s bed.
Discard used equipment appropriately.
Perform hand hygiene.
Taking these step ensures the patient’s continued safety.
23. Document procedure and findings according to agency policy. Record dressing
change as per hospital policy.
24. Compare wound to previous wound assessment and determine healing progress, if any.
Indications:
Proper wound care is necessary to prevent infection, assure there are no other associated
injuries, and to promote healing of the skin. An additional goal, if possible, is to have a good
cosmetic result after the wound has completely healed.
Contraindications:
Infection
When the bacterial load within the wound reaches greater than 10 organisms per gram of
tissue, there is an increased risk of wound infection. Inadequate debridement is often the
cause for persistent infection. Exposed bone or hardware is presumed infected and should be
debrided or removed if possible.
Age
Aging has shown to delay wound healing in healthy adults without actually impairing the
healing quality.
Nutrition
Malnutrition delays wound healing and alters immune system function, thus increasing the
risk of infection.
Steroids
Corticosteroid use affects wound healing by impairing inflammation and collagen production
as well as inhibiting epithelialization.
Smoking
Nicotine impairs wound healing through its vasoconstrictive effects and increased risk of
thrombus formation.
Diabetes
Diabetes is a well-known risk factor for wound complications due to hyperglycemia and
vascular impairment. Poor control, both long-term and perioperatively, is associated with
increased risk of infectious and non-infectious wound complications.
Cancer
Cancer patients are at significant risk for impaired wound healing due to both the nature of
disease as well as the multimodal treatment they undergo.
Chemotherapy
Multiple animal studies have demonstrated decreased wound strength after neoadjuvant or
adjuvant chemotherapy, especially in the early postsurgical period.
Radiation
Ionizing radiation causes DNA damage and acute microvascular occlusion and stasis that
predisposes tissue to edema, thrombosis, and poor healing.
Possible Complications:
1. INFECTION
2. OSTEOMYELITIS
3. GANGRENE
4. PERIWOUND DERMATITIS
5. PERIWOUND EDEMA
6. WOUND DEHISCENCE
7. HEMATOMAS
Nursing responsibilities:
Provide excellent nursing care to patients suffering from wounds.
Assess and evaluate patients with wounds and injuries.
Obtain cultures to assess wounds and injuries.
Evaluate wounds and injuries for infections or other illness factors that causes wounds.
Initiate nursing care procedures in managing acute and traumatic wounds.
Coordinate with rehab, traumatic and nutritional nurses in nursing patients with wounds.
Ensure optimum patient care delivery in wound care nursing procedures.
Educate and counsel patients and their families on wound care processes and issues.
Demonstrate wound care procedures to other care givers.
Sanitize and maintain the premises of wound care neat, clean and hygienic.
Assess for:
heat, redness, swelling, and pain.
increased exudate
delayed healing
contact bleeding
odour
abnormal granulation tissue
