ED nurses assume new role in wound care

Standing orders permitting early anesthetization and irrigation of wounds speed healing

ED nurses should play a key role in management of wound care, stresses Robert Herr, MD, MBA, FACEP, former corporate chairman of emergency medicine for FHP International and currently a Salt Lake City, UT-based consultant in emergency medicine. "Nurses need to anesthetize the wound and, after a quick neurological evaluation, begin the process of irrigation," he says.

Nurses should begin wound care before the patient sees a physician, he urges. "In terms of infection, irrigation is far more important than anything else that could be done to the wound," he says. "With contaminated wounds, it’s even more important that the process start immediately, and that requires teamwork."

Tips to consider when managing a wound

Don’t delay irrigation. EDs should have standing orders or protocols for nurses to anesthetize the wounds and perform copious wound irrigation. "It’s not only better for patient care, it’s also more efficient," argues Herr. "You’re removing an entire step from the process, because you’re not waiting around for a physician to show up and say, OK, it’s a wound and start irrigating it’," he says. "That’s a great example of how the process can be streamlined through a teamwork approach to wound care."

Delays in irrigation increase the chance of infection, he says. (To learn which wounds are at high-risk for infection, see the box on page 61). "Patients shouldn’t have to wait while a resident discusses the wound with a physician," Herr says. "A study of training centers found that academic centers had a much higher rate of wound infection and that was directly related to delays in irrigating the wounds."

Lay patient down to clean the wound. Wound care should be carried out in the supine position, advises Alexander Trott, MD, professor of emergency medicine at the University of Cincinnati College of Medicine (OH). "Patients with even minor wounds are susceptible to vasovagal syncope in the ED, so they should be lain down prior to any intervention," he says.

Another advantage to using the supine position is limiting the patient’s visibility. "I’ve also seen a lot of patients who are sitting up faint while getting their wound cleaned. They look at the blood and get woozy, and down they go," says Trott.

Avoid excessive soaking of wounds. Soaking can be used to loosen external dirt or caked blood, but you shouldn’t go overboard. "Nurses tend to plop the patient’s feet and hands into buckets of saline and Betadine, but that doesn’t do anything to clean the average wound," Trott says. "It’s a waste of supplies, and it can be misleading, because some people think if you soak a wound you don’t need to do anything else."

Don’t scrub the wound. Irrigate the wound, as opposed to washing the wound with a sponge, Trott emphasizes. "Scrubbing the skin doesn’t get into the wound," he says. "You need high-pressure irrigation through a syringe."

Use universal precautions. Use a wound irrigation device with a splash shield for protection against splashing bodily fluids. "Most people are appropriately concerned about engaging in universal precautions when dealing with a major trauma patient, but they don’t take it as seriously with lacerations," says Trott. Managing wounds can be just as risky, so nurses should use appropriate protections, such as eye shields, mask, and gloves, or a full face shield.

Don’t overlook other symptoms. Patients with minor wounds tend to be triaged to minor care areas, which is dangerous if those minor wounds are hiding bigger problems. It’s not uncommon for a major underlying illness to be missed," says Trott. "A patient may present with a small cut on their forehead, but that cut may have been caused by cardiac arrhythmia which caused the patient to faint and hit their head. Meanwhile, the only thing anybody sees is a cut."

Use nonadherent layers under wound dressing. After applying an antibacterial ointment, use a nonadherent layer, such as Adaptic, between the wound and the bandage, recommends Barbara Birmingham, RN, clinical coordinator for trauma and burns service for the University of Alabama at Birmingham. "It may be tempting to skip that step if it’s really busy, but you don’t want the bandage to yank at the stitches and pull the wound apart," she says.

Don’t shave hair to clean wounds. Even with scalp wounds, it’s not necessary to shave hair, says Trott. "Hair can be cleaned just as well as skin can," he advises. "If you shave down to the skin, it increases rate of infection and cause bacterial penetration. Wash the skin or clip long hair with scissors."

Give clear follow-up instructions. Patients should be given clear discharge instructions to reduce the risk of infection. Points to stress are keeping the wound dressing dry and clean, changing as needed, and keeping the wound elevated to reduce swelling, says Trott.

Nurses should be sensitive to patients’ needs to ensure they get follow-up care, Birmingham recommends. "In the ED, you should have some idea of how much antibiotics cost, and before they are prescribed, make sure the patient will be able to afford them," she says. "Otherwise, you might have to work through social services or come up with a cheaper antibiotic."

Give local anesthetic before cleaning a wound. "You need to make sure there is no dirt or dead tissue left behind in the wound, with a thorough cleansing and debridement," Trott explains. "Cleaning the wound will hurt a patient, and sometimes the nurse won’t be as aggressive if a patient is complaining of pain."

Don’t be rough. Be thorough yet gentle when cleaning a wound, without applying excessive pressure. "If you’re too rough, you can cause tissue damage," Trott notes.

Don’t depend on antibiotics. Antibiotics are no substitute for good wound preparations, Trott stresses. "Some people think if we just give antibiotics that will take care of it, but wound infection is prevented by how well you clean and prepare a wound, not by giving antibiotics," he says.