Have you talked to staff about wounds lately?

Wound care critical to improving patient outcomes

Healing wounds and preventing bedsores will be far bigger challenges in months to come as managed care pressures reduce the number of visits nurses make to treat home care patients.

So wound care education has become a top priority at some home care agencies. Both nurses and home care aides need to know how to prevent skin breakdowns, and nurses must be kept abreast of the latest wound treatments.

St. John’s Visiting Nurse Association of Springfield, MO, developed an in-depth wound care inservice for nurses at their request.

"When I did a learning needs assessment for staff last year, one of the requests was that we have more education on wound care," says Lori Mitchell, RN, BSN, patient/staff education coordinator for the full-service agency that serves a mostly rural area in southwestern Missouri and northwestern Arkansas.

"We know that wounds are a very costly area, and with managed care coming along, we wanted to standardize our care for faster wound healing, and we wanted to focus on prevention," Mitchell adds.

Likewise, wound care is one of the major areas of concern at Baptist Home Services of Montgomery, AL, says Susan Douglass, RN, BSN, quality assurance/education coordinator for the hospital-affiliated agency that serves Montgomery County.

"We have a lot of wound care patients," Douglass says, adding that the agency has tried to improve its wound care through inservices for nurses, aides, and hiring a wound ostomy nurse. (See story on teaching aides about preventing skin breakdown, p. 24.)

Education managers who would like to put together their own wound care inservices for nurses may find these guidelines helpful:

1. Pull together wound care resources.

Mitchell used the guidelines for prevention and prediction of pressure ulcers developed by the Agency for Healthcare Policy and Research in Washington, DC. She purchased a book of the full guidelines for each office.

She put information on a flip chart, printed hand-outs on wound care, and developed an outline pressure ulcer treatment. (See outline on prevention and treatment of pressure ulcers, p. 21.)

2. Discuss wound complications.

Mitchell told nurses how wound complications can be very costly and painful.

One of the most expensive complications resulting from a wound is osteomyelitis, which is when the patient has an infection in the bone. "That’s a major complication of a pressure ulcer infection that is going very deep," Mitchell says.

Another infection includes sepsis, which is a systemic type of infection that gets into the blood stream.

Wound complications also may include disfigurement and a recurrence, Mitchell notes.

A major ulcer that does a great deal of tissue damage may not heal completely, leaving disfigurement that may require plastic surgery, she explains.

"Also when a pressure ulcer occurs, you never have the same strength in that tissue as you did initially," Mitchell states. "It’s only about 80% of the original strength of the skin, so the tissue in that area is much more apt to break down again because it is never as strong."

3. Go over risk assessment tools.

Mitchell discussed two major tools: the Braden Scale for Predicting Pressure Sore Risk, created by Barbara Braden and Nancy Bergstrom1, and the Norton Scale, created by Doreen Norton, Rhoda McLaren, and A.N. Exton-Smith.2

The Braden Scale features six categories that measure on a scale of one to four the degree to which a patient is limited or impaired. One is "completely limited," and four is "no impairment." These categories include the following:

• how well the patient can respond to pressure-related discomfort;

• how much the skin is exposed to moisture;

• how active the patient is;

• how well the patient can change and control body position;

• the patient’s usual eating pattern;

• friction and shear.

The Norton Scale lists five categories with a scale from one (very bad) to four (good). These are:

• physical condition;

• mental condition;

• activity;

• mobility;

• incontinence.

"I stressed that any tool alone won’t take care of all the patient’s risks," Mitchell says. "Patients with specific risks might be a person who has diabetes or circulatory problems or someone who has a suppressed immune system."

Then Mitchell covered the four stages of wounds as approved by the National Pressure Ulcer Advisory Panel. (See the four stages of pressure ulcers, p. 22.)

4. Teach about risk indicators.

• The first risk indicator is pressure, such as the pressure applied to the patient’s bony prominence, including the tailbone or elbow, Mitchell says.

Other areas for pressure would be over the hip, on the heel, on the ankle bone, etc.

• Another major indicator is friction and shear. Shear occurs when deep tissue slides because of a position change, but the skin surface stays stationary.

"What happens is it’s almost like you’re pulling in two different directions on the skin, and it damages the capillaries and impairs circulation," Mitchell explains.

Shear can occur when a patient’s bed is raised at the head because if the patient has a pressure ulcer, the deep tissue will stay in the same position while the skin moves.

Friction occurs when the patient slides up or off the bed. "This is when the outside layers are pulled against something or are slid onto something," Mitchell says. "You need to lift and not slide the patients."

• Next, the patient’s nutritional status may indicate risk for pressure ulcers. Patients who have low albumin, a protein in the blood, may be malnourished and thus susceptible to pressure ulcers, Mitchell says.

So nurses need to check the patient’s diet and frequency of meals, possibly consulting with a dietitian.

• Moisture can create an environment that encourages pressure ulcers. This includes sweating and incontinence.

"It’s necessary that we teach the caregiver to keep the patient clean and dry because the skin is just much more prone to break down if it gets real wet," Mitchell advises.

Very dry skin also can break down, so the patient’s skin should be rubbed with skin cream, heavy ointment, or any kind of petroleum-based or aloe-based ointment, she adds.

• The patient’s immobility is another risk factor. Patients will need to be turned at least every two hours, Mitchell states.

If a caregiver will have difficulty turning a patient, then the home care agency might need to supply the family with a mattress that reduces pressure.

• The last risk factor is sensory perception. Patients who have no feeling in parts of their body, such as paraplegics and quadriplegics, are prone to skin breakdown because nothing hurts them, and they’re also immobile, Mitchell says.

"We see lots of quadriplegics with pressure ulcers, and they may not be bedridden, but they’re in a wheelchair for long periods of time," Mitchell says. "And their skin has a tendency to break down because they don’t change positions often."

5. Touch on principles of wound management.

Mitchell teaches nurses these principles:

Debridement. This is cleaning the wound. There are four basic types of debridement, including:

— Sharp debridement: This is when the wound tissue is cut away by a surgeon or someone who is specially trained.

— Chemical debridement: Medications are placed on the wound bed.

— Mechanical debridement: This includes dry dressing, hydrotherapy, or water pick devices. "You can use a 19-gauge angiocath connected to a 35 cc syringe," Mitchell says. "That exerts about eight psi [pounds per square inch] to the wound bed, and you don’t want a whole lot of psi because that can damage healthy tissue."

— Autolytic debridement: This is when a moisture retentive dressing is placed over the wound to keep moisture inside. "That’s the most natural way to debride an ulcer," Mitchell says. "It takes longer, but it’s not very painful like cutting away tissue."

This method also involves using wet-to-dry dressings. But this is costly and requires dressing changes two or three times a day.

Cleanse the wound.

Normal saline is most often used, but nurses sometimes use a surfactant-based mild cleanser to spray on the wound.

Preserve periwound skin.

Nurses need to keep the outside of the wound moisturized but not wet. "We don’t want the contents of the wound bed getting on the good skin," Mitchell says.

So nurses should preserve the wound skin and contain the secretions of the wound by using absorptive dressing and skin sealants and skin barriers. The goal is to protect the granulation tissue, which is the healthy tissue that is rejuvenating or rebuilding inside the wound bed. This is done with a protective dressing, maintaining a moist wound bed, proper positioning, and by using devices, such as a therapeutic bed.

Prevent or eradicate infection.

Nurses must prevent pooling exudate, the wound drainage, by getting underneath the deepest portion of the wound and making sure there is an absorptive dressing loosely packing it. "You have to fill in that wound space to absorb the exudate in the wound," Mitchell adds.

Other good infection control measures should be followed, including washing hands, wearing gloves, and teaching the family the same precautions.

Promote healing.

Make sure the patient receives good nutrition, extra calories, infection control measures, and controlling metabolic disorders, such as high blood sugar.

"We want to improve circulation and decrease edema," Mitchell says.

Obliterate dead space.

These are the open spaces in the wound that can be obliterated by packing the undermining areas loosely. Loosely packing also prevents the trapping of fluid in the wound.

Provide patient comfort.

"One thing we sometimes forget is how painful wounds can be," Mitchell notes. "There are patients who need stronger analgesics, narcotics for pain control."

Also, odor control may be a problem that creates some discomfort for the patient. So sometimes nurses will use a deodorizer or peppermint cotton ball in the room.

References

1. Braden B, Bergstrom N. Braden Scale for Predicting Pressure Sore Risk. 1988.

2. Norton D, McLaren R, Exton-Smith A.N. An investigation of Geriatric Nursing Pproblems in the Hospital. London: National Corporation for the Care of Old People (now the Centre for Policy on Aging); 1962.