Wound Care and the Nursing Process

Eric Christofferson, RN, BSN, CWON

Disclosures
• I have no financial disclosures to report
• I am an employee of Altru Health System
• Brand names may be mentioned in this presentation, however these are only used as a
reference. This is by no means an endorsement of a particular product or company.

Assessment
Plan
Intervention
Evaluation

Objectives
1. Use wound care terminology to describe a wound
2. Understand how to prepare a wound bed for healing
3. Identify several different wound care treatments currently in practice
4. Evaluate wound healing progress and identify common barriers to healing

Assessment
Assessment: Subjective
• How did it start?
• Duration of wound
• Pain is important
Assessment: Objective
• Surrounding edema and redness
• Temperature
• Color, quality, and amount of exudate
• Are wound edges open or closed?
• Tunneling vs Undermining
• Tissue types in wound
• Location
Assessment: What is bioburden?
• Bacterial biofilm
• Band together to create matrices
• Matrices can secrete enzymes, proteins, and sugars
• Can impede wound healing
Assessment: Tissue Quality
• Healthy tissue
• Granulation
• Epithelial
• Bleeding
• Dead or dying tissue (necrosis)
 • Slough
• Ischemic
• Eschar
Assessment: History
• Medical history
• Surgical history
• Medications
• Prior wound history
• Risk factors
• Nutritional assessment
• Patient socioeconomic factors

Treat the whole patient, not just the hole in the patient!

Plan
Planning: moist wound healing
• What is moist wound healing?
• History
• Evidence-based
• When is it contraindicated?
Planning: advantages of moist wound healing
• Enhances cell migration
• Promotes angiogenesis
• Augments autolysis
• Lessens risk for wound infection
• Improves thermoregulation
• Fosters pH balance
• Enhances patient comfort
• Decreases healing time
Plan: wound bed preparation
It’s about TIME
• Tissue nonviable or deficient
• Infection or inflammation
• Moisture imbalance
• Edge of wound advancing or non-advancing
Plan: Debridement
Autolytic
*Enzymatic (collagenase)
*Biological
Mechanical
*Sharp
*Surgical (multiple disciplines often overlap)
 * Requires advanced practice licensure or higher

Intervention
Intervention: Dressing selection
• Exudate management
• Frequency of dressing changes
• Managing bioburden
• Overall cost to patient
• Clean or sterile dressing changes?
• No evidence to show that sterile dressing changes decrease chance of infection
• Some wounds may benefit
• Clean technique is appropriate for vast majority of wounds
Intervention: traditional dressings
• Woven and unwoven gauze
• Emollient gauze
• Transparent semi-occlusive dressings
• hydrocolloids
Intervention: antiseptics
• ¼ strength Dakins (0.125% bleach)
• Iodine
• Povidone iodine (about 10%)
• Cadexomer iodine (less than 5%)
• Acetic acid (vinegar) about 1%
• Hydrogen peroxide- do not use
Intervention: antimicrobials
• Leptospermum (Manuka) honey
• Ionic silver
• Methylene blue and gentian violet
Intervention: advanced dressings
• Calcium alginate
• Foams
• Composite dressings
• Collagen matrices
• Negative Pressure Wound Therapy
Intervention: other advanced treatments
• Biological tissue (stem cells)
• Growth factors
• Hyperbaric oxygen

Evaluation
Evaluation: the healing process
• Hemostasis
• Inflammation
• Proliferation
 • Remodeling
Evaluation: chronic wounds
• Failure to heal within 30-60 days
• Refractory
• No improvement within 2-4 weeks of evidence-based treatment
• Investigate when wounds stall in healing process
• Wounds that fail to heal in a typical manner might need biopsy
• Restarting process through sharp debridement
• Open vs closed edges
Evaluation: interdisciplinary team
• Vascular medicine
• Vascular surgery
• Plastic surgery
• Infectious disease
Evaluation: interdisciplinary team (continued)
• Occupational therapy
• Prosthetics and orthotics
• Evaluation by dietitian
• Palliative care
• Wound goals should coincide with patient goals
Evaluation: wound closure
• Primary intention
• Secondary intention
• Care of chronic wounds
• Tertiary intention

References

Black, C. E., & Costerton J. W. (2010). Current concepts regarding the effect of wound microbial
ecology and biofilms on wound healing. Surgical Clinics of North America, 90(6), 1147–1160.

Doughty, D. & McNichol, L. (2016). Core Curriculum wound management. Wound, Ostomy, and
Continence Nurses Society. Wolters Kluwer.

Kent, D. J., et al. (2018) Does the Use of Clean or Sterile Dressing Technique affect the Incidence
of Wound Infection? Journal of Wound Ostomy Continence Nursing, 45(3):265-269.

Rutter, L. (2017). Obtaining the optimum moist wound healing environment. British Journal of
Community Nursing, 22, S36–S40. 

Wang, C., Guo, M., Zhang, N., & Wang, G. (2019). Effectiveness of honey dressing in the
treatment of diabetic foot ulcers: A systematic review and meta-analysis. Complementary
Therapies in Clinical Practice, 34, 123–131. 
White, R., Cooper, R., & Edwards-Jones, V. (2012). What Is the Role of Biofilms in Wound
Healing? Wounds UK, 8(2), 21–25.