Home health nurses seek education in wound care

Teaching strategies for wound care inservice

When managed care policies limit the number of home health visits, prevention of chronic wounds — and treating them quickly and effectively when they do appear — becomes exceedingly important. Wound care education has assumed prominence at many home care agencies determined to help their field staff achieve the best outcomes.

While many home health nurses have some knowledge of chronic wound treatment, there still is a gap that needs to be filled so nurses, as well as aides, can keep abreast of the latest wound treatments and protocols.

At St. John’s Visiting Nurse Association of Springfield, MO, the nurses themselves requested and received an in-depth wound care inservice that focused on the basic concepts of wound care.

"When I did a learning needs assessment for the 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.

Focus on prevention

"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 inservice programs for nurses and aides and by hiring a wound ostomy nurse.

Following are some of the teaching strategies Mitchell and Douglass use in their educational programs:

Pull together wound care resources. Mitchell started with the Guidelines for Prevention and Prediction of Pressure Ulcers developed by the Agency for Health Care Policy and Research in Rockville, MD. She purchased a book containing the full guidelines for each office. She also put information on a flip chart, printed handouts on wound care, and developed an outline for pressure ulcer treatment.

Discuss wound complications. Many home care nurses may not be familiar with wound complications and their potentially devastating consequences. Mitchell tells her nurses to keep an eye out for infection and other serious problems. One of the most expensive and debilitating complications resulting from a wound is osteomyelitis, which is when a wound infection reaches the underlying bone.

Mitchell emphasizes to her nurses that a wound that has appeared to heal still must be watched carefully for signs of recurrence.

"When a pressure ulcer occurs, you never have the same strength in that tissue as you did initially," Mitchell explains to her nurses. "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."

Review risk-assessment tools. Mitchell introduces two widely used assessment tools to her colleagues: the Braden Scale for Predicting Pressure Sore Risk, created by Barbara Braden and Nancy Bergstrom, and the Norton Scale, created by Doreen Norton, Rhoda McLaren, and A.N. Exton-Smith.

Mitchell reviews the six categories of the Braden Scale that measure on a scale of one to four the degree to which a patient is limited or impaired. A rating of one is "completely limited," and four is "no impairment." The categories include:

— 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.

Next she covers the Norton Scale, which lists five categories on a scale from one (very bad) to four (good). These are:

— physical condition;

— mental condition;

— activity;

— mobility;

— incontinence.

"I stress 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."

Mitchell also covers the four stages of pressure sores approved by the National Pressure Ulcer Advisory Panel.

Teach about risk indicators. Mitchell reviews the three most common risk factors for pressure ulcers among bedridden patients: pressure (such as is applied to the patient’s bony prominences), friction, and shear. All three can damage capillaries and impair circulation. Mitchell stresses to her nurses the importance of instructing family members to turn or reposition patients often.

Discuss nutrition. To heal, wounds need protein reserves from which to draw. It’s been clearly shown that patients with low blood albumin levels are at increased risk for pressure ulcers. Mitchell instructs nurses to check patients’ diet and frequency of meals, and to consult with a dietitian if needed.

Nurses also are told to be aware of moisture, such as from incontinence or sweating, which can accelerate wound formation.

"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 wet," Mitchell advises.

Mitchell also tells her nurses that, conversely, very dry skin also is prone to break down. She instructs her students to rub a patient’s dry skin with skin cream, heavy ointment, or any kind of petroleum- or aloe-based ointment.

Patients who have lost sensation in parts of their bodies, such as paraplegics, quadriplegics, and those with diabetic neuropathy, are prone to skin breakdown because they can’t sense the pain that is a precursor to the development of wounds.

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

Mitchell also touches on a number of other areas of wound management during her inservices:

Perform debridement (sharp, chemical, mechanical, and autolytic) correctly.

Cleanse wounds properly. Mitchell tells her nurses that normal saline is most often used, but sometimes a mild surfactant-based cleanser can be sprayed on the wound as well.

Preserve periwound skin. Nurses need to keep the outside of the wound moisturized but not wet. "You don’t want the contents of the wound bed spreading outside of the wound, getting on the good skin," Mitchell says. She teaches that wound secretions can be contained using absorptive dressing, skin sealants, and skin barriers. The goal is to protect the granulation tissue in the wound bed while keeping skin around the wound intact.

Prevent or eradicate infection. Mitchell emphasizes the need to practice basic infection control activities, such as hand washing, gloving, and the appropriate use of clean or sterile technique. The family, she says, should be taught appropriate precautions as well.

Prevent the pooling of wound exudate. This can be achieved by making sure the deepest portions of a wound are loosely packed with an absorptive dressing.

Promote healing. Make sure patients receive an adequate diet that is high in protein and has sufficient caloric content. Metabolic disorders, such as high blood sugar, also should be addressed and controlled.

Obliterate dead space. Undermined or tunneled portions of wounds must be lightly packed with an absorptive dressing to prevent wound exudate from being trapped.

Provide patient comfort. "One thing we sometimes forget is how painful wounds can be," Mitchell notes. "Some patients need stronger analgesics, such as narcotics, for pain control." Odor control also may be a problem that creates discomfort for the patient. Nurses are instructed to use a deodorizer or peppermint cotton ball in the room.