8.3 Wound Management

Hemostasis

Immediately after an injury, hemostasis (i.e., cessation of bleeding) occurs through vasoconstriction of blood vessels in the area, deposition of fibrin, and formation of blood clots through blood platelets. The blood clots provide a matrix of fibrin that becomes the framework for cell repair. After vasoconstriction, exudate is formed when the blood vessels expand, increasing capillary permeability, which allows plasma and blood components to leak out into the injured area. Pain and swelling may occur as a result of the buildup of exudate. Heat and erythema are the outcome of increased perfusion. Scabs form on the wound surface to protect the injury when blood clots lose their fluid. Epithelial cells migrate under the scab to provide a barrier between the body and the environment and to prevent the entrance of microorganisms.

Inflammatory Phase

Following hemostasis, the inflammatory phase begins and lasts about two to three days. During this phase phagocytosis occurs when leukocytes and macrophages move into the interstitial space to ingest bacteria and cellular debris. The macrophages also release angiogenesis factor that stimulates the formation of epithelial buds at the ends of injured blood vessels. The growth factor attracts fibroblasts that help fill in the wound. This phase may be depicted by pain, redness, heat, and swelling at the injury site. The patient may have a general body response such as a slightly elevated temperature, elevated number of white blood cells, and general discomfort.

Proliferation Phase

The proliferation phase is also known as the reconstructive, fibroblastic, regenerative, or connective tissue phase. This phase begins around day three or four and may last up to several weeks. Fibroblasts that migrated to the wound begin to synthesize collagen, a whitish protein substance that adds flexible strength to the wound. Collagen synthesis peaks in five to seven days, although the collagen deposits may persist for several weeks or years depending on the size of the wound. The fibroblasts also produce specialized growth factors that prompt blood vessel formation and proliferate the amount and migration of endothelial cells. Capillaries grow across the wound, increasing the blood supply and oxygen needed through a process called angiogenesis.

Fibroblasts move from the bloodstream into the wound to deposit fibrin. As the capillary network develops, the tissue becomes translucent red, a granulation tissue that is delicate and bleeds easily. This granulation tissue provides the framework for scar tissue development. Wounds that heal by first intention have epidermal cells that seal the wound within twenty-four to forty-eight hours, and granulation tissue would not be evident. Wounds that were not sutured need the injury site to be filled in with granulation tissue. After maturation of the granulation tissue, marginal epithelial cells migrate to the site, proliferating over this connective tissue base to fill in the wound.

By the end of the second week after the injury, the majority of white blood cells have left the wound area, making the wound lighter in appearance. The generalized symptoms the patient had generally disappear by this point. Adequate nutrition and oxygenation are essential patient care considerations for this phase. Any wound closed with sutures or other type of closures should be prevented from experiencing any type of strain, such as the patient lifting something heavy or pulling the patient in a way that adversely affects the injury site.

Maturation Phase

The maturation phase is the final phase of wound healing and begins around day twenty-one; it can last up to months or years. Fibroblasts continue to synthesize collagen during this phase. The collagen fibers are reorganized into an orderly structure in this phase and promote a stronger wound. The collagen also aids in making the wound more like its neighboring tissues. When new collagen continues to synthesize, the blood vessels in the healing wound compress so that the scar does not sweat, tan in sunlight, or grow hair. The scar becomes a flat, narrow line and is not as elastic as uninjured tissue. The scar becomes stronger, but the tissue in the repaired area is never as strong as original tissue. Wounds healed by secondary intention may take longer to remodel and form a scar. When scars form over a joint or adhere to body structures, arthrofibrosis occurs which may limit mobility or cause a disability. For example, arthrofibrosis occurs when scar tissue forms around the knee joint after knee surgery, which limits the range of motion.

Localized Factors

A localized wound healing factor (e.g., desiccation, maceration, trauma, pressure, excessive bleeding and edema, or infection) directly affects the wound and may delay the process of healing. Meticulous care is necessary with wound management to prevent or limit these factors that can impede wound healing. It is important for nurses to understand these factors to promote optimal outcomes, improve wound care, improve the patient’s quality of life, and prevent significant healthcare costs.

Systemic Factors

A systemic wound healing factor is one not related to the wound itself. These factors take place throughout the body and include age, venous insufficiency, poor oxygenation, obesity, diabetes, medications, and smoking or alcohol use. In addition, wound etiology directly affects the process of wound healing. Wounds that are the result of a systemic issue, such as a venous ulcer, may recur. Nutritional status plays a significant role in wound healing as adequate carbohydrates, proteins, fats, minerals, fluids, and vitamins are needed to rebuild cells and tissues, promote epithelialization and collagen synthesis, and support optimal cell function. Patient adherence to the treatment plan is also a crucial element of wound healing. Patients who are noncompliant can experience negative effects on wound healing. Protein supplements may be necessary to meet wound-healing needs in patients who are unable to adequately take in the necessary proper nutrition.

Pain

Any type of trauma can cause pain no matter the size of the injury. Pain is a physical complication but has a substantial psychological element. Wound pain may be caused by coughing, moving in bed, dressing changes, ambulating, or other activities that require movement. Pain attributed to these activities may result in the patient hesitating or avoiding them altogether. Pain can be debilitating to the affected persons and often lead to depression, further contribute to stress, cause fear and anxiety, and disrupt overall activities of daily living. Pain can also cause altered vital signs such as tachycardia, tachypnea, and elevated blood pressure. Nursing interventions to reduce pain can reduce discomfort and emotional stress. For example, administering pain medication before performing wound care may reduce the amount of pain during the process.

Fear

Fear is a common response to wounds. The pain and disruption to activities of daily living can contribute to anxiety and fear. Patients are often concerned about the wound-healing process and complications that may arise, such as wound dehiscence (partial or complete opening of a wound) and infection. They may also be worried about other people’s responses to the wound appearance or smell as well as how much their privacy will be invaded when undergoing wound care. The fear of rejection may lead to social isolation. Nursing interventions should include therapeutic conversation that encourages expression of feelings, answering questions honestly and accurately, exhibiting empathy and acceptance, and preventing excessive exposure of body parts during care.

Disruption to Activities of Daily Living

Wound management can be tedious and time consuming and disrupt a person’s routine. The physical, medical, and financial burdens or restrictions can limit a person’s ability to perform their activities of daily living. Pain associated with the wound may also affect their independence. Being unable to perform self-care, homemaking, work, leisure, or social activities can have a negative effect on the life of the patient and caregiver.

Altered Body Image

A negative body image can damage a person’s self-esteem. The skin is part of what gives someone their identity; therefore, any wound or trauma requires adaptation of the concept of self. This may make a person self-conscious when scars or wounds are visible to others. Scars on the face or ones that take up a large margin of skin may result in diminished self-worth or feelings of ugliness. This type of negative self-image can lead to social isolation, further exacerbating the other stressors associated with wound management. Nursing interventions are similar to that of fear and include therapeutic conversations encouraging expression of feelings, answering questions honestly and accurately, exhibiting empathy and acceptance, and referring patients and their caregivers to support groups or counselors who can aid in coping skills and acceptance.

Infection

Wound infections are common. Wounds are by their nature “dirty” and contain bacteria. However, not all wounds are infected. When the immune system fails to limit microbial growth, wound infection occurs. The invasion of microorganisms can occur at the time of the injury, during surgery or postoperatively, or any time after the injury. People with suppressed immune systems or who are undergoing myelosuppressive cancer treatment are more susceptible to infection. Wounds contaminated at the time of injury (e.g., knife or gun wounds) are more prone to infection than an uncontaminated wound. Surgeries involving the intestines increase the risk of infection because of feces and microorganisms inside the intestines. Most surgical-related infections are apparent two to eleven days postoperatively.

To be considered infected, a wound must include pain, redness, swelling, and purulence (Nagle et al., 2023). Table 8.9 provides signs and symptoms of wound infections that should be routinely monitored (Bishop, 2021).

Hemorrhage

Some wound bleeding is normal. Massive bleeding (i.e., hemorrhaging) is abnormal and may be caused by a dislodged clot, slipped stitch, or erosion of a blood vessel by a foreign body. If possible, any dressings should be checked frequently during the first forty-eight hours after the injury and at least every eight hours thereafter. In the event of excessive bleeding, interventions may include packing or applying a pressure dressing, performing surgery, replacing fluids, and monitoring vital signs. Internal bleeding may result in a hematoma, a localized collection of blood under the skin that may appear reddish blue and swollen. A large hematoma can be hazardous because it places pressure on blood vessels and causes tissue ischemia.

Dehiscence and Evisceration

The most serious wound complications include dehiscence and evisceration (Figure 8.9). Smoking, obesity, malnourishment, anticoagulant therapy, excessive coughing, vomiting, infected wounds, or straining increase the risk of dehiscence and evisceration. The partial or total rupturing of a sutured wound is called dehiscence and is caused by excessive stress on unhealed wounds. Dehiscence may be preceded by the presence of serosanguineous fluid from the wound postoperatively. It is common for the patient to say, “It feels like something has given way.” The dehisced wound is managed like an open wound. The protrusion of the viscera through the incision when the wound completely separates is called evisceration. This occurs most commonly with abdominal incisions.

Figure 8.9 Dehiscence and evisceration are serious complications. Dehiscence may occur from strenuous activity such as coughing or vomiting and can lead to evisceration. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

These complications should be treated like a medical emergency. The patient should be placed in the low Fowler’s position and the area should be covered with a sterile towel soaked with sterile 0.9 percent sodium chloride. Placing the patient in the low Fowler’s position and slightly bending their knees will lower intra-abdominal pressure on the wound. This will prevent more wound damage until the physician arrives. The provider should be notified immediately because surgical intervention is required. Other nursing interventions include remaining with the patient, providing reassurance, administering intravenous pain medications as needed, and ensuring that the patient remains NPO (nothing by mouth).

Fistula

A fistula is an abnormal passage from one internal organ or vessel to another or an internal organ or vessel to the outside of the body. Fistulas may be created on purpose, such as an arteriovenous fistula to provide access for kidney dialysis. However, with wound complications, infection can lead to the development of a fistula from an abscess. The collection of undrained infected fluid applies pressure on the surrounding tissue, creating the abnormal passage. Fistulas increase the risk of prolonged healing, skin breakdown, additional infection, and fluid and electrolyte imbalances.

Assessment and Documentation

Wound assessment and documentation are crucial aspects of the nurse’s role with managing wounds. Some facilities (e.g., long-term facilities, outpatient clinics, or home care) may take weekly photos to show the progression of the wound healing.

Wound assessment is an ongoing process that requires thorough evaluation and clear, concise documentation for adequate tracking of the healing progression. This allows for continuity of care, adequate care evaluation, and proper interventions or changes in wound care. All photos should be taken with a measuring device (e.g., ruler) placed by the wound to indicate proportions and should be documented and dated for an accurate timeline. In addition to the assessment findings, documentation should also include wound care or therapies provided during the encounter, how well the patient tolerated it, any medications administered and the patient response, any communication to the provider of abnormal findings and whether new orders were received, and any education or supplies given to the patient or family members as well as their understanding of the teaching.

Positioning Devices

Patients who have pressure injuries or have been identified as at risk may benefit from positioning devices to aid in preventing pressure injuries or promote healing. Examples of positioning devices include gel interfaces, foam wedges, or pressure-reducing boots that can be positioned to keep pressure and body weight off bony prominences. If possible, avoid using pillows or other surfaces that collapse under the patient’s body weight. These do not provide adequate support. Ring cushions (i.e., donuts) should not be used because they can cause increased venous pressure in the surrounding areas.

Dressings

Wounds may be left open to air or covered with a protective dressing. Wounds may be left open to air per provider order if closing the wound makes infection more likely. Wounds left open to air develop dried eschar or a scab, leading to slower healing. The scab may be inadvertently removed if the area is rubbed or something hits the wound, causing reinjury. Dressings used to cover wounds provide a moist environment that promotes healing. This moist environment aids in rapid epithelial cell migration, maximizing the healing process. Dressings should also be absorbent, provide a barrier from bacteria, limit pain at the wound site, provide thermal insulation, and permit pain-free removal. Covered wounds help patients cope with the change in their body image.

There is a wide array of dressings used when managing wounds. Different dressings are appropriate for different locations or types of wounds and different stages of wound healing. Although there are many types of dressings, all share the same purposes:

• They provide physical, aesthetic, and psychological comfort.
• They prevent, eliminate, or control infection.
• They absorb drainage.
• They provide moisture balance.
• They guard the wound from added injury.
• They protect the skin around the wound.
• They debride necrotic or damaged tissue, if applicable.
• They promote or optimize the healing process.
• They allow for ease of use and cost effectiveness.

The frequency of dressing changes may not always adhere to a set schedule. Often providers will perform the first dressing change after surgery to afford them the opportunity to assess the incision site. This is generally done twenty-four to forty-eight hours after the procedure. The provider will then write orders dictating the frequency of future dressing changes and products to be used. Excessive moisture can lead to complications. Microorganisms can migrate into the wound site through saturated dressings or from the outer surface of a saturated dressing. Therefore, dressings that are oversaturated or saturated will require more frequent changes or reinforcement with additional dressings. Dressing changes allow for an opportune teaching moment, so that the nurse can demonstrate dressing changes that the patient can do at home. The nurse should encourage the patient to help as much as possible to verify accurate understanding.

Sometimes the patient can struggle with the sight of the wound and not want to look at it. The nurse should listen to what the patient says and pay attention to nonverbal communication. The nurse should provide emotional support and remain patient. Patients with wounds can learn to manage and adjust with the proper support and encouragement.

Various types of wound dressings are available depending on the location, size, depth, and type of wound; the type and amount of drainage; and whether infection is present and debridement is needed. The provider may also have preferences that influence the type of dressings used. The dressings may change as the healing process progresses. The basic primary dressings are those that add, absorb, or maintain moisture. It is the nurse’s responsibility to be aware of the products available in the facility they work in and the indications for the various dressing types.

Dry gauze dressings are commonly used to cover wounds, especially surgical-related wounds (Figure 8.10). Dry gauze dressings come in different sizes, such as 2 in x 2 in (5 cm x 5 cm), 4 in x 4 in (10 cm x 10 cm), and 4 in x 8 in (10 cm x 20 cm), and often have multiple layers. They are commonly packaged as single units or in multipacks. The first layer is applied directly to a draining wound and is capable of carrying moisture but is nonabsorbent. This allows the wound to drain into overlying absorbent layers in an attempt to prevent maceration or infection. This dressing type does not commonly stick to the wound and reduces the risk of causing discomfort to the patient. In the event the dressing does stick, sterile saline can be used to loosen the gauze to prevent further injury.

Figure 8.10 Dry gauze is commonly used to dress wounds. (credit: “Braided-mesh gauze” by National Library of Medicine, CC BY 4.0)

The next layer is material that will absorb and collect drainage. Cotton-lined gauze sponges or loosely packed gauze wrap (Figure 8.11) are great options because of their ability to pull drainage out by capillary action. The number of gauze sponges or gauze wrap needed is dependent on how much drainage is present. The next layer may be surgical or abdominal pads (ABDs) that help absorb copious amounts of drainage.

Figure 8.11 Gauze wrap can be loosely packed into a dressing to help pull moisture away from a wound. Gauze can also be used as a secondary dressing to hold another type of dressing in the wound bed. (credit: modification of “Combat Gauze” by U.S. Army Materiel Command/Flickr, CC BY 2.0)

Nonadherent gauzes are semipermeable and may be used to allow drainage to pass through and be absorbed by the outer layer. This type of dressing also prevents the outer dressings from adhering to the wound and decreases the risk of injury when removed. Examples include sterile petrolatum gauze and Telfa (i.e., nonabsorbent, nonadherent dressing gauze) gauze and are commonly used on incisions closed with staples or sutures. Precut dressings, such as the Sof-Wick dressing, are available that fit around drains and tubes. Transparent films (e.g., Tegaderm) are semipermeable membrane dressings that are waterproof and adhesive. These dressings reduce the chance of contamination, are occlusive, and allow for visibility of the wound (Figure 8.12). This type of dressing is commonly used over noninfected healing wounds or intravenous sites.

Figure 8.12 Using a transparent dressing to cover an IV site allows the nurse to monitor the insertion site for complications. (credit: "Medics practice their skills" by Master Sgt. Brad Staggs/Defense Visual Information Distribution Service, Public Domain)

With any type of wound, the goal is to keep the wound tissue moist while the surrounding tissues and skin remain dry. This requires continuous dressing monitoring and ensuring the moist dressing solely covers the wound. An absorbent dressing should be used that maintains the wound moisture. The surrounding healthy skin should be kept intact and dry. Moisture-barrier ointments and skin sealants may be used on the healthy skin. The dressings covering the wounds should be secured with the most minimal amount of tape possible or nontape products (i.e., Coban self-adherent wrap).

When foreign material is present, debridement may be necessary. Dressings that promote autolytic debridement include hydrocolloid or transparent films. These occlusive dressings promote the use of the body’s own enzymes and defense processes to loosen or soften necrotic tissue. Vacuum-assisted closure (VAC) may also be necessary to promote healing of difficult wounds or in patients with risk factors for delayed healing (such as older adult patients with chronic health conditions) (Agarwal et al., 2019).

Before performing a dressing change, the nurse should inform the patient regarding what will be done. If indicated, prescribed analgesics may be administered thirty to forty-five minutes before the dressing change to limit discomfort associated with dressing changes. Dressing changes should be planned between meals to avoid ruining a patient’s appetite. Privacy should always be provided for the patient during dressing changes. The patient should be in the most comfortable position possible throughout the process. Only the necessary area should be exposed during dressing changes, ensuring that the rest of the patient remains draped.

Appropriate aseptic techniques should be used to prevent infection or reinfection. Proper hand hygiene should be performed before and after dressing changes and standard and transmission-based precaution should be followed appropriately. Dehisced surgical wounds require use of sterile technique. Pressure injuries do not require sterile dressings. Nonsterile gloves may be used when providing clean wound care.

Bandages and binders apply pressure and support the wound in addition to secure the dressing. Bandages that may be used include Kerlix, roller gauze, or ACE (All Cotton Elastic) bandages to wrap a body part to secure the dressing. Rolling bandages are applied starting at the distal end of the area. One hand holds the free end in place while the other hand passes the roll around the body part. Once anchored, the roll is rolled around the body part in a figure eight or circular motion, applying equal tension in all turns and going in the direction of the heart to avoid venous stasis and edema. Each turn should overlap the previous turn by one-half to two-thirds (Figure 8.13).

Figure 8.13 Bandages are wrapped in a figure-eight style to provide maximum support at points both above and below the affected joint. (credit: modification of “Ankle bandage” by U.S. Navy/Wikimedia Commons, Public Domain)

Binders are designed for a specific part of the body such as abdominal binders, shoulder slings, or chest binders. T-binders are used to secure rectum or perineum dressings. A double T-binder is used for males, and a single T-binder is used for females. The belt should be passed around the waist and then the tails should pass between the legs prior to fastening. Typically, the binders are made of cloth or elasticized material that can be fastened with Velcro. Montgomery straps are ties that attach to an adhesive backing that holds a dressing in place. They are useful in preventing skin irritation or tissue damage when retaping is necessary for repetitive dressing changes. The patient’s skin should be protected with a skin barrier or hydrocolloid dressing before applying the Montgomery straps. The adhesive backing is applied to the adjacent skin with the ties extending over the wound area. The straps should be untied and turned back during wound changes and retied after the new dressing has been applied.

Drains

Drains are often used with wounds that are expected to have an accumulation of fluid that would impede wound healing (Table 8.10). Drains may be placed during surgery to prevent fluid collection underneath the incision site. Drains, tubes, or catheters may be used in or near the wound site. These are commonly used after surgical procedures in which the surgeon places one end of a drain or tube near or in the area to be drained and passes the opposite end through the skin, through either the incision or a different opening (i.e., stab wound). Drains are either closed or open systems.

Type	Examples	Image
Closed drainage systems have a tube connected to a portable reservoir that provides continual low suction. These are typically sutured to the skin and require emptying to reestablish suction when needed.	Jackson-Pratt drain Hemovac	(credit: modification of “Surgical drain – waste container” by "26RIJNA2020"/Wikimedia Commons, Public Domain)
Negative pressure wound therapy is a type of closed drainage system that uses a special sponge that works with a semi occlusive barrier that connects to a drainage system.	Vacuum-assisted wound closure	(credit: “KCI Wound Vac01” by "Noles1984"/Wikipedia, Public Domain) (credit: “KCI Wound Vac02” by "Noles1984"/Wikipedia, Public Domain)
Open drainage systems do not have a collection device. The drainage empties from the wound or surgical site into absorbent dressings. These are typically sutured in place. The provider may order reducing the length of the drain inside the wound each day. This may be done by clasping the end of the drain with sterile forceps, then pulling it out a small distance using a twisting motion, and then cutting off the end with sterile scissors. A new sterile pin should be placed at the base as close to the skin as possible.	Penrose drain	(credit: “Compartment syndrome in the hand Intraoperative image of the dorsal region of the right hand” by "Mimarx"/Wikimedia Commons, Public Domain)

Table 8.10 Different Types of Drains

Sutures and Staples

Sutures and staples are placed by the surgeon or provider to close the wound edges but may be removed by the nurse as ordered. They may be removed after the wound is strong enough to hold its edges together. The length of time needed to develop tensile strength varies among individuals and depends on wound location, age, and nutrition level of the patient. Silk sutures are generally removed after six to eight days to avoid marks; however, the collagen formation and remodeling can take up to three weeks. This may lead to stretching or widening of the scar after the sutures are removed.

A suture removal kit is used to remove sutures, and there is a special staple remover for taking staples out. Sterile technique is used during the removal. Hand hygiene should be performed before and after the procedure. The nurse should explain the process to the patient before starting. Any dressings covering the site should be disposed of appropriately. The incision should be cleaned from the center of the wound moving outward. Every other suture or staple should be removed to assess proper healing of wound edges. If the wound is healing properly, then the remaining sutures or staples may be removed. Small, adhesive wound-closure strips may be applied over the wound to provide support as wound healing progresses, or another dressing type may be applied depending on facility policy or provider preference.

The following are specific instructions for suture removal using the appropriate kit:

1. Use the sterile forceps to grasp the first suture knot and gently lift.
2. Use the sterile scissors to cut one side of the suture underneath the knot and close to the skin.
3. Ensure the knot is still being grasped with the forceps and pull the cut suture through the skin. (The suture should be pulled through by the section of the suture that has been inside the tissue).

Following are specific instructions for staple removal using the appropriate sterile staple remover:

1. Gently position the staple remover under the staple that is being removed.
2. Securely close the remover to straighten the ends of the staple, being careful not to lift up while disengaging the ends of the staple.
3. Gently lift upward with the remover to remove the staple from the incision. If there is resistance, remove one side of the staple and then the other side.

Cleaning

Wound cleaning is essential to help remove microorganisms or debris and protect healthy granulation tissue. Normal saline solution (i.e., 0.9 percent sodium chloride) is the typical cleaning agent used in wound care. However, there are other products available such as cleaning antiseptic or surfactant sprays that may be used with infection, debris, or increased amounts of bacterial colonization. Wounds are cleaned after the old dressings have been removed and before applying new dressings. The technique for cleaning wounds with approximated edges differs from wounds with unapproximated edges (Table 8.11).

Open wounds may need to be irrigated during the cleaning process. Irrigation is a direct flow of a sterile solution over the tissues using sterile equipment. Sterile water or sterile 0.9 percent sodium chloride, antiseptic, or antibiotic solutions may be used depending on the provider’s order and wound condition. The solution is delivered to the wound using a sterile, large-volume syringe. The wounds may need to be packed and dressed after irrigation to absorb drainage and promote healing of secondary intention. If wound edges are approximated, nonsterile solutions may be used to clean the skin surface.

Growth Factors

Growth factors are naturally occurring polypeptides involved in essential cellular processes needed for tissue regeneration. Growth factors bind to their corresponding receptors on the cell surface to induce signaling pathways to initiate signaling molecules that can stimulate cytoplasmic proteins or prompt the transcription of new proteins (Park et al., 2017). The only exogenic growth factor that has shown to be efficient in treating chronic wounds is the recombinant platelet-derived growth factor (PDGF). This growth factor is synthesized outside the human body and stimulates the immune cells and fibroblasts to prompt the development of the extracellular matrix. Growth factors may be applied topically to the wound by the nurse with an order from the provider.

Hyperbaric Oxygen Therapy (HBOT)

A more advanced wound care therapy is hyperbaric oxygen therapy (HBOT). This technology expedites repair of compromised healing wounds. Patients undergoing this therapy are placed in a pressurized, hyperbaric chamber for generally one to two hours where they breathe 100 percent oxygen. This amount of oxygen enhances the amount of oxygen dissolved in the plasma and also promotes cell proliferation and healing. A highly concentrated oxygen environment boosts wound metabolism, enhances the response to growth factor, activates angiogenesis, and provides antioxidant and antibacterial effects to enhance immune function. Nurses work under the supervising provider to administer this therapy to patients. Patients should be supervised throughout the entire treatment and monitored for adverse effects such as oxygen toxicity, claustrophobia, middle ear injuries, or pneumothorax. Fragranced hygiene products, medical devices such as eyeglasses or hearing aids, jewelry, flammable objects, and electronics should be avoided while inside the chamber (Alemayehu et al., 2019).

Heat and Cold Therapy

Heat and cold therapy may be used with wound management. Heat may accelerate the inflammatory cascade of the wound-healing process. The application of heat causes vasodilation, which increases blood flow, reduces blood viscosity, increases capillary permeability that improves delivery of nutrients and leukocytes, helps with pain relief, and reduces muscle tension. Heat may be applied by a moist method (e.g., sitz baths, soaks, warm moist compresses). Dry heat methods include electric heating pads, hot water bags, chemical heat packs, or dry heating pads powered by hot water (aquathermia).

Sitz baths may be used on the pelvic, rectal, or perineal areas. It may be used after childbirth or to relieve discomfort from a fissure or hemorrhoids. A sitz bath is most often performed on the toilet with a tub lining the bowl. The tub is filled with 3 to 4 in (7.5 to 10 cm) of warm, not hot, water. A bathtub with a special chair and basin may also be used. The patient will submerge their pelvic area for twenty to thirty minutes to aid in reducing inflammation.

Warm soaks consist of the patient submerging a part of their body into warm water or a medicated solution. The warm soak enhances blood supply to the infected area, applies medication to the wound, assists in cleaning sloughing wounds, and improves circulation. The basin or container should be sterilized or cleaned vigorously to reduce the risk of pathogens. The temperature should be between 105ºF to 109ºF (40.6ºC to 42.8 C). The soak may take fifteen to twenty minutes, so the water temperature should be monitored and maintained as needed by discarding some of the fluids every five minutes and replacing them with fresh warm water or solutions. The patient should remove their body part from the container during this process. The container being used should be positioned to promote comfort and proper body alignment.

Moist, warm compresses are used to promote healing and blood flow to the area and also reduce edema. Compresses may be prepackaged supplies from a manufacturer or used by soaking a cloth or towel in hot water and wringing out the excess. A small wet towel can also be placed in a closed plastic bag and warmed in the microwave for one to two minutes after wringing out the excess water. The nurse should test the compress to ensure it is not too hot. This method may cool rapidly due to evaporation, so the compresses should be changed frequently and covered with a heating pad, hot water bottle, or Aqua-K pad. Nurses should monitor the tissue integrity around the wound, ensure the water is not too hot for the patient, and ensure the area is not overhydrated.

Electric heating pads provide even, consistent heat, and they are generally safe to use. The pad can be applied locally to the area and may be used if covered by facility protocol. The patient may be required to sign a release form. The pad should be used according to manufacturer instructions to avoid injury. Pins should be avoided with the use of heating pads because they pose a risk of shock. The pad should be covered with a moistureproof covering that is not too heavy. The heating pad should not be under the body part, or between the body part and a surface such as a mattress, because it could result in burning the linens or the patient. The heating pad should be one that has a limit on how high the pad can be turned up to avoid burning the patient. The nurse should instruct the patient to use the lowest heat setting and not to bypass the auto shutoff to help prevent burns. The nurse should monitor the patient’s skin regularly for discomfort, sensation changes, or redness.

Hot packs provide a certain amount of heat within an allotted time frame. They come with instructions on the package that describe activation, which may require squeezing or kneading the pack or even hitting it on a hard surface. The nurse should follow manufacturer directions and follow precautions by monitoring the patient as with the other types of heat therapy methods.

Cold therapy causes vasoconstriction, minimizes muscle spasms, and promotes comfort. Cold therapy also may use dry methods such as cold packs or ice bags. Moist methods include using cold moist compresses. The skin should always be monitored for redness, patient comfort, and sensation changes with any type of cold therapy. In addition, modalities that may have moisture or leakage should be monitored to avoid skin breakdown or overhydration.

Like hot packs, cold packs are also commercially prepared and are sealed containers filled with a nontoxic or chemical substance. Some packs may be kept in the freezer or triggered by squeezing the substance that creates the cold. These packs are easy to mold to fit the body part being used. They should also be covered with a cotton sleeve so that the pack can be slid onto the extremity or just placed on top of the body part.

Ice bags are inexpensive and fairly easy to use. The bag should be filled about two-thirds full with small pieces of ice. Ice cubes are more difficult to mold to the body part than smaller pieces such as ice chips. Air should be removed from the bag, and the cap should be secured. It is important to ensure the bag does not leak, and a cover should be placed over the ice pack in the event of moisture. The ice pack should only be used for twenty to thirty minutes at a time with an hour break in between uses to prevent overexposure to cold. Patients may use bags of frozen vegetables in place of ice bags at home.

Like their counterpart, moist cold compresses are local applications. They can be used for hemorrhoids or eye injuries. The thickness and texture of the material used are dependent on the area of the body on which it is applied. For example, a washcloth is appropriate for the face whereas a special oval-shaped gauze is appropriate for the eye. The material being used should be submerged in a clean basin or container that has ice and water. The excess water should be removed prior to application. The compress may need to be changed regularly over the twenty-minute therapy because the temperature of the compress will change. The application may be repeated every two to three hours or as ordered. Commercial devices or ice bags may be used to aid in maintaining the cold of the compress.

Debridement

The removal of slough or necrotic tissue and foreign material by various methods is called debridement.

There are three types of debridement:

• Using occlusive dressings to enhance the body’s own defense mechanisms to liquefy or soften necrotic tissue is called autolytic debridement.
• Applying commercially prepared enzymes that accelerate the body’s autolytic process is enzymatic debridement.
• Applying external physical force to remove debris or necrotic tissue is known as mechanical debridement. This method may be accomplished through wound irrigation with pulsed pressure lavage, ultrasound, laser therapy, surgical debridement, or whirlpool therapy.

Wet-to-dry dressings may still be ordered with debridement although there are concerns that this method interrupts angiogenesis. If this method is ordered, it is important that the nurse ensure that the product being used supports moisture balance and that there is no dry gauze in the wound.

Surgical intervention may be warranted when other treatment options have been unsuccessful in wound healing. Surgical interventions may include skin grafting, skin flap procedures, or wound closures. Surgical debridement may also be needed when other debridement techniques have failed, or the extent of the necrotic tissue warrants surgery. Surgical interventions may be selected depending on the patient’s condition as well as the severity of the wound. Nursing wound management interventions include ensuring protection of the wound from pressure and infection. Physician orders should be followed for wound care.

Wound Care Education and Health Promotion

Education is a vital component of a nurse’s care of patients, particularly when the nurse is preparing the patient for discharge. Education should include the patient and their family members. Continuity of care, whether it is the patient going home or being transferred to another facility or unit, is essential to promote healing and prevent infection or worsening complications. Education may also be taught during home care as well. Education may include at-home wound care and pressure injury prevention.

Patients and their families should be taught about risk factors for pressure injuries, how and where these injuries may arise, and prevention strategies. Any instructions or illustrations provided should be written at a level the patient can understand and in their preferred language. Other education should include proper hand hygiene before and after care as well as the signs and symptoms of infection.

Education and health promotion should include adequate nutrition and hydration to promote wound healing. The nurse should assess for any deficiencies and make recommendations as needed. Regular visits with the provider should also be encouraged, which allows the provider to oversee the progression and quality of wound healing. This also allows the provider to make changes to the healing and wound care processes as needed. If the patient complains of pain associated with wound care, the nurse should educate the patient on using pain medication thirty to sixty minutes before wound care is provided.

Any education provided to the patient and their family should be evaluated. The patient and family should verbalize understanding or give a return demonstration. The patient or family should be encouraged to participate in wound care, so that the nurse has a chance to reinforce or confirm proper care techniques.

Teaching Self-Care at Home

Teaching self-care at home should cover supplies, infection prevention, and wound healing. Supplies should be easily attainable so the patient can perform care at home. The nurse should consider cost and ease of use when making recommendations on how the patient can obtain supplies. Most supplies are available from a medical supply store, discount store, drug store, or pharmacy. The patient may have preferences in regard to the location of the store relative to their home. Insurance companies may reimburse or provide financing for supplies, so the nurse should encourage the patient to follow up with their insurance provider.

Infection prevention is paramount with wound healing because infection can slow wound healing or cause further complications. The nurse should provide education on proper hand hygiene, glove usage, and wound care steps. The patient and family should be educated on signs and symptoms of infection and when to notify the provider. Signs and symptoms include fever, flu-like symptoms, increased pain, thick drainage with a foul odor that may be yellow tinged, and red or separated wound edges. The education should also include instructions on proper disposal of old dressings (e.g., putting old dressings in a plastic bag and placing them in the trash bin).

Wound healing self-care should focus on promoting optimal healing. The education should cover balanced nutrition that is high in protein and vitamins as well as drinking at least 48 to 64 oz (1.5 to 109 L) of hydrating fluids. Rest periods should be encouraged during the day to avoid overexertion or injury. The patient may also need modifications surrounding their activities of daily living until the healing is complete. The provider may have restrictions or recommendations to follow, which should be taught to the patient. The family should be educated as well to be able to help the patient and ensure compliance. Patients who struggle with an altered body image or difficulty coping with the wound and activity restrictions may benefit from counseling in a group setting or with a one-on-one therapist.