Learning Objectives
By the end of this section, you will be able to:
- Examine the phases involved in wound healing
- Identify complications to wound healing
- Educate patients and caregivers on self-care of wounds at home
Wound management encompasses many nursing interventions that are essential for promoting healing and regeneration of tissues. Different techniques are used to treat wounds, such as applying dressings or leaving the wound open to air. The technique or intervention used is dependent on the type of wound present. To effectively manage wounds, nurses must understand the phases of wound healing, factors affecting wound healing, psychological effects of wounds, complications affecting wound healing, and the nurse’s role in wound care management.
There are three types of wound healing: primary, secondary, and tertiary intention healing. When wound edges have been approximated with little to no tissue loss and show formation of nominal granulation tissue and scarring, this is known as primary intention healing. For example, a surgical incision closed after surgery using sutures or a liquid adhesive is primary intention healing. These wounds are easily closed in a line formation. The healing process of extensive wounds that have significant tissue loss making approximating edges difficult or not a good option is called secondary intention healing. Pressure injuries are examples of secondary intention healing. Secondary intention healing takes longer, has more scarring, and is more susceptible to infection. Delayed primary intention, or tertiary intention healing, occurs in wounds that are intentionally left open for three to five days to allow edema or infection to resolve or to let any exudate to drain. After that period of time, the wounds are closed with sutures, adhesive closures, or staples.
Phases of Wound Healing
Wound healing can be broken down into the following phases: hemostasis, inflammatory phase, proliferation phase, and maturation phase (Figure 24.16). There are three phases of wound healing: inflammatory, proliferation, and maturation; in this case, hemostasis is included as part of the inflammatory phase. After an injury, the body automatically undergoes these phases, which methodically lead to tissue repair.
Hemostasis
Immediately after an injury, hemostasis (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, when leukocytes and macrophages move into the interstitial space to ingest bacteria and cellular debris, phagocytosis occurs. 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 like 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 a translucent red, 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 making granulation tissue not 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.
The majority of white blood cells have left the wound area making the wound lighter in appearance by the end of the second week after the injury. 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 types of closures should be prevented from experiencing any type of strain, for example, picking up 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 and 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 normal 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.
Circumstances Affecting Wound Healing
There are several factors that influence the speed of wound healing. Localized factors are those factors that occur directly in the wound or directly influence the wound’s characteristics. On the other hand, systemic factors occur throughout the body due to a disease state or overall health of the individual and their body’s ability to promote healing. Some factors may be related, and systemic factors act through the local effects that can impact wound healing (Monika et al., 2022).
Localized Factors
Desiccation, maceration, trauma, pressure, excessive bleeding and edema, or infection are all localized wound healing factors that directly affect 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.
Desiccation
Unintentional wound or tissue dehydration, known as desiccation, occurs when cells do not get adequate moisture, so they dry up and die. This cell death leads to a crust that forms over the wound site, which impedes healing. This can occur naturally as part of the wound healing process or as a result of external factors such as exposure to air, inadequate wound dressing, or excessive use of wound irrigation solutions. While a certain level of desiccation is normal and may promote wound healing by facilitating the formation of a protective scab, excessive desiccation can impede the healing process. Prolonged drying of the wound bed can lead to tissue dehydration, delayed epithelialization, and increased risk of infection. Additionally, desiccation can cause discomfort and pain for the patient as well as impair the migration of cells involved in wound repair.
Maceration
Just like a wound can get too little moisture, there can also be an excess of moisture. Maceration is softening and breakdown of the skin due to overhydration. A common cause of maceration is urinary and fecal incontinence. This type of moisture also causes changes in the pH level of the skin, destroys skin from friction on moist skin, and causes overgrowth of bacteria or infection of the skin that in combination leads to maceration and impaired skin integrity.
Infection
Infection is often caused by bacteria or other microorganisms in the wound. Infection puts a strain on the affected person’s body because of the increase in demand for energy by the immune system to combat microorganisms. This strain leaves little or no energy for the body to promote the process of repair and healing. Bacteria also produces toxins and releases them when they die, which further affects wound healing and leads to cell death.
Systemic Factors
Healing factors that are not related to the wound itself, called systemic wound healing 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 may recur like a venous ulcer. 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 epithelization 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 intake the proper nutrition needed.
Age
Skin changes are a normal part of aging. However, these changes can adversely affect an older adult’s wound healing. Vascular changes (e.g., atherosclerosis, capillary atrophy) can impede blood flow. Collagen is less elastic, which increases the risk of injury or damage by pressure, friction, and shearing. Immune system changes can decrease antibody and monocyte formation, which is needed for wound healing processes to occur. Older adults may also be deficient in nutrients and fluids needed or have chronic conditions that impair oxygen delivery to wounds (e.g., chronic lung disease). Cell renewal is slower in older adults and results in prolonged healing.
Venous Insufficiency
Venous ulcers caused by venous insufficiency can lead to an increase in pressure and buildup of fluid in the lower legs. This generally is the result of high blood pressure, long periods of sitting or standing, lack of exercise, smoking, deep vein thrombosis, obesity, tissue trauma, and phlebitis. This combination leads to cell death, tissue damage, or wounds because of a lack of nutrients and oxygen. Blood flow is needed to not only deliver nutrients and oxygen but also to remove bacteria, toxins, and other debris. Therefore, wounds caused by venous insufficiency or another source are at risk of delayed wound healing.
Poor Oxygenation
Oxygen is essential for the biological processes that take place within the phases of wound healing like angiogenesis and collagen synthesis. Poor oxygenation may be due to systemic factors like diabetes or advanced age. It may also result from any factors that impair vascular flow to the tissues. A lack of oxygen prolongs healing and can lead to cell death. Oxygen also has antimicrobial effects and plays a vital role in the inflammatory response. People with poor oxygenation are more susceptible to infection, which further complicates wound healing.
Diabetes
Diabetes negatively affects wounds. Diabetes impairs circulation needed to deliver oxygen and nutrients. Uncontrolled blood sugar can damage the nerves and cause numbing sensations known as diabetic neuropathy. This reduced sensation means that the affected person may not be aware of the wound resulting in the lack of or delayed intervention. Uncontrolled blood sugar levels also impair white blood cell function needed to fight bacteria and close wounds in the inflammatory response.
Medication
Some medications may have an adverse effect on wound healing. Steroids affect the inflammatory phase and decrease its response. Radiation results in decreased leukocytes and increases the chance of infection because of depressed bone marrow function. Chemotherapeutic agents may impair or stop the growth of new cells needed for wound healing. Patients who have prolonged antibiotic use are at risk of secondary infection or superinfection (e.g., Clostridioides difficile). This means that the infection is unrelated to the original infection and results from opportunistic colonization following immunosuppression. Medications used to treat skin disorders inadvertently cause thinning of the outermost layer of the skin, increasing susceptibility to breaks in the surface.
Wound Complications
There are several events that can interfere with wound healing and may cause complications. Infection, hemorrhage, dehiscence and evisceration, and fistulas can increase the risk of death or generalized illness, increase healthcare costs, and prolong the need for healthcare interventions. These complications can also exacerbate the emotional stressors associated with wounds.
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 (Figure 24.17). 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. Table 24.11 provides signs and symptoms of wound infections that should be routinely monitored (Bishop, 2021).
| Sign/Symptom | Examples |
|---|---|
| Wound bed | Bright red, fragile granulation tissue with pockets |
| Exudate | Increased exudate, cloudy, yellow, green, pus, smelly, leaking around wound closures |
| Periwound area | Redness, inflammation, streaks leading out from wound |
| Swelling | Unusual swelling near the wound and nearby swollen lymph nodes |
| Fever | Typically seen in combination with other symptoms |
| Pain | Increasing in intensity, new, or changed from previous pain |
Hemorrhage
Some wound bleeding is normal. Massive bleeding (or 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, surgical intervention, fluid replacement, 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 24.18). Smoking, obesity, malnourishment, anticoagulant therapy, excessive coughing, vomiting, infected wounds, or straining increases 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 days 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 and most commonly occurs with abdominal incisions.
These complications should be treated like a medical emergency. The patient should be placed in the low Fowler 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 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.
Psychological Effects on Wound Healing
Wounds can be debilitating and have a significant effect on a person’s self-identity and emotional well-being. The skin plays a role in communicating with other organs in the body through its sensory functions and affects a person’s self-image. Patients can experience anxiety, post-traumatic stress disorder, and depression from how the wound is created based on it being a traumatic injury, either intentional or nonintentional, and emotions contribute to the patient’s overall well-being in the outcome. Wounds and pressure injuries cause stress and emotional factors related to pain, fear, disruption to activities of daily living, and an altered body image. These stressors are interconnected and can impact not only the patient but also their caregiver or loved ones.
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. It can be debilitating to the affected persons. Pain can 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 like 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 response 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 encouraging expression of feelings, answering questions honestly and accurately, exhibiting empathy and acceptance, and preventing excessive exposure of body parts during care.
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 unattractiveness. 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.
Clinical Judgment Measurement Model
Recognize and Analyze Cues
Before recognizing cues, nurses must make sure they have enough information about a patient’s situation before interpreting the information and developing a plan of care. For example, patients experiencing fear related to their wound may have anxious feelings about wound care, pain, rejection from others, or how this wound will affect their life. The nurse should assess the patient’s feelings and gather information about activities of daily living, how much support or help the patient has at home, and any other aspects affecting the patient’s self-identity and mental well-being. The nurse should also be aware of nonverbal cues during care (e.g., looking away, grimacing) to assess discomfort or unease.
Nursing Interventions Used in Wound Management
Wound care requires an interdisciplinary approach and may require a number of nurses and other healthcare providers to work together. It is essential that nurses understand their role in wound care management to effectively implement interventions within their scope of practice. The nursing role includes assessment and documentation, positioning, dressing care, drain care, suture and staple care, cleaning, debridement, administering growth factors, heat and cold therapy, wound care education and health promotion, and teaching the patient to perform self-care at home. Other therapies that the nurse may be required to assist with include hyperbaric oxygen therapy and surgery. It is important to note that wound care is not 100 percent dictated on the bedside nurse, it can vary based on specialty background and acute care area. If nurses truly desire to become experts in wound care, they can achieve additional certification and become a certified wound care nurse (CWCN) and ostomy care nurse (CWCON), and they would be a bigger member of the interdisciplinary team.
Assessment and Documentation
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 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 cause 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 rubs or 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.
Binders are designed for a specific part of the body like 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.
Unfolding Case Study
Unfolding Case Study #4: Part 6
Refer to Unfolding Case Study #4: Part 5 for a review of the patient data.
| Nursing Notes | 1600: Focused skin assessment performed. Open wound noted on bottom of left foot. Patient reports stepping on broken glass about a month ago but states, “I assumed my foot was fully healed because it doesn’t hurt at all.” Upon assessment, the wound is red with purulent drainage and surrounded by edematous tissue. Prophylactic dressing applied to sacral area. Provider notified. |
| Provider’s Orders | 1700:
|
Drains
Drains are often used with wounds that are expected to have an accumulation of fluid that would impede wound healing (Table 24.12). 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 bulb drain Hemovac |
(credit: modification of “Surgical drain – waste container” by Wikimedia Commons, Public Domain)
|
| Negative pressure wound therapy is a type of closed drainage system that uses a special sponge that works with a semiocclusive barrier that connects to a drainage system. | Vacuum-assisted wound closure |
(credit: “KCI Wound Vac01” by Noles1984/Wikimedia Commons, Public Domain)
(credit: “KCI Wound Vac02” by Noles1984/Wikimedia Commons, 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 Belzunegui T, Louis CJ, Torrededia L, Oteiza J - Scand J Trauma Resusc Emerg Med/Wikimedia Commons, Public Domain)
|
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.
Cleaning
Wound cleaning is essential to help remove microorganisms or debris and protect healthy granulation tissue. Normal saline solution (0.9 percent sodium chloride) is the typical cleaning agent used in wound care. However, there are other products available like 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.
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. 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
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 like oxygen toxicity, claustrophobia, middle ear injuries, or pneumothorax. Fragranced hygiene products, medical devices like glasses or hearing aids, jewelry, flammable objects, and electronics should be avoided while inside the chamber (Alemayehu et al., 2019).
Link to Learning
Patients may be unsure about hyperbaric oxygen therapy and may ask for a reference to review at home. The Food and Drug Administration provides an overview of hyperbaric oxygen therapy for consumers to review.
Debridement
The removal of slough or necrotic tissue and foreign material by various methods is debridement. Along with removal of dead tissue and bacteria, this process stimulates growth factor to promote wound healing. In autolytic debridement, occlusive dressings are used to enhance the body’s own defense mechanisms to liquefy or soften necrotic tissue. Applying commercially prepared enzymes that accelerate the body’s autolytic process is enzymatic debridement. In mechanical debridement, external physical force is applied to remove debris or necrotic tissue. 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.
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. 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.
Patient Conversations
Nutrition Education to Support Wound Healing
Scenario: A nurse is providing discharge education to a patient with a stage III pressure injury that will be transitioning to the outpatient wound clinic. During the education, the nurse realizes that the patient does not currently intake enough protein.
Nurse: All right. So, we have covered everything in your discharge plan. I would like to go more in depth with you about nutrition to ensure we are promoting your healing process. Is that okay?
Patient: Sure. I guess I just don’t understand why it matters.
Nurse: Nutrition is vital in the healing process. When your body does not have adequate nutrition, it struggles to promote the adequate healing process. Things like protein, vitamin C, and fluids are important to intake in adequate amounts. If you have any deficiencies, it may lead to further skin breakdown, electrolyte imbalances, inadequate circulation, and swelling. All of those either slow healing or inhibit it all together. Does that make sense?
Patient: It does. I drink about 100 ounces of water a day, and I take a daily vitamin. How do I know if I am getting enough protein in?
Nurse: That is a great question. This actually varies from person to person. Studies have shown that wound healing requires 1.5 grams of protein per kilogram each day (Saghaleini et al., 2018). So, I see here that you weigh 155 pounds and that would equate to 106 grams of protein a day. You can either write down what you eat or track it in an app on your mobile phone to ensure you meet that daily goal.
Patient: Oh, like that MyFitness Pal my daughter put on my phone?
Nurse: Yes sir. Have you used it before?
Patient: Well, I played with it when she first installed it. It seems pretty easy. I just stopped using it when I was in the hospital.
Nurse: Okay. Do you need help using it at all?
Scenario follow-up: The patient got his phone out and opened the app. The patient was able to input various food items with little assistance. This return demonstration allowed the nurse to assess that the patient was able to perform this task.
Nurse: I am glad you are able to use the app. If you do not want to use an app, you can always keep a handwritten food journal. What kind of protein do you usually enjoy eating?
Patient: Steak or any kind of beef, cheese, and pork.
Nurse: Okay, do you enjoy chicken, eggs, or any dairy products?
Patient: Yeah, I do, and I do eat those.
Nurse: Great. Those are also great sources of protein as well as nuts, seeds, nut butters, beans, lentils, and edamame.
Patient: Oh, I do enjoy a lot of those as well. Sometimes I only eat breakfast and dinner, so I do not think I get 106 grams of protein in a day. I just have not been hungry lately.
Nurse: You can supplement your diet with things like protein shakes or drinks to aid boosting your protein intake. I have a list here that I am going to send you home with. It includes protein and other food groups that support wound healing.
Patient: That will be great. My wife would like that.
Nurse: Of course.
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, drugstore, or pharmacy. The patient may have preferences in regard to the location of the store 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 it in the trash bin).
Wound healing self-care should focus on promoting optimal healing. The education should cover balanced nutrition high in protein and vitamins as well as drinking at least forty-eight to sixty-four ounces 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.