Wound Care and
the Nursing Action –
A Simple Nursing Guide
A wound is a break or cut in the continuity of any body structure, internal or external caused by physical means.
Purpose of Wound Care and the Nursing Action:
Purpose:
To prevent infection.
Nursing Action:
1. Prevent the wound with appropriate dressings to prevent wound contamination.
2. Use sterile techniques.
3. Clean the wound thoroughly.
4. Isolate patients with clean wounds from those with contaminated wounds.
5. Use antiseptics on and around the wounds.
6. Use systemic antibiotics.
2. To prevent further tissue damage.
Nursing Action:
1. Protect the wound with adequate dressings to prevent friction.
2. Handle injured tissues as little as possible to prevent the destruction of new granulation tissues.
3. Immobilize the injured part by using slings, bandages, splints or plaster casts.
4. Use antiseptic solutions of correct strength which are safe for the skin and mucus membranes. Using antiseptics of high concentrations can cause tissue injury.
5. Apply surgical soak when the dressings are adhered to the wound.
3. To promote healing.
Nursing Action:
1. Approximate the wound edges with sutures.
2. Keep the wounds clean and dry.
3. Supply essential nutrients in the diet.
4. Ensure good blood supply by removing tight bandages and dressings.
4. To absorb inflammatory exudates and to promote drainages.
Nursing Action:
1. Apply absorbent cotton or gauze to absorb the inflammatory exudate.
2. Drainage tubes are put in, to promote drainage and to prevent collection of fluid in the tissues.
3. Suction may be applied to the drains to facilitate the drainage of wounds.
4. Elevate the injured part to increase the venous return of blood to the heart and to prevent swelling at the site of injury.
5. To convert the contaminated wound into a clean wound.
Nursing Action:
1. Special attention is given to the wounds that are filled with pus and necrotic debris.
2. These wounds should be thoroughly cleaned to remove the pus and the dead tissues.
3. Stagnant blood clots should be removed to prevent multiplication of bacteria.
4. Wound may be irrigated with sterile solutions to remove the tissue debris and pus in order to reduce the number of bacteria in the wound.
5. Surgical debridement of wounds i.e., excising by a scalpel any dead tissues or slough that are present in the wound.
6. Incision and drainage of abscess will help to remove any abnormal collection of exudates which acts adversely to wound healing and promote bacterial growth.
7. Remove any foreign material, e.g., a piece of glass, which have been stuck up in the wound at the time of injury.
6. To prevent haemorrhage.
Nursing Action:
1. Apply pressure dressings when there is bleeding.
2. Identify the bleeding points and ligate them.
3. Apply ribbon gauze packing into the body orifices where bleeding is expected. E.g., after the surgery of the rectum or vagina.
7. To prevent skin excoriation.
Nursing Action:
1. Change the dressings frequently when it is wet with wound drainage.
2. Apply water-proof ointments (e.g., zinc oxide) to the surrounding skin areas when there is constant drainage from the wound.
3. Frequent removal of adhesive tapes can be irritating to the skin. When the dressing are to be changed frequently, it should be secured with bandages instead of adhesive plaster.
4. Pad the bony prominences adequately before the application of the adhesive plaster.
8. To apply the medications in place.
Nursing Action:
1. Medications are applied over the part and the dressings are applied to keep them in place for a sufficient period of time.
9. To restore the functions of the part.
Nursing Action:
1. Avoid constrictive bandages.
2. Dressings are placed in such a way that it will not interfere with the functions of the body parts.
3. Place the body part in a functioning position before immobilizing the part.
4. When there are wounds involving two skin surfaces, separate the skin surfaces with adequate paddings, so that adhesions will not be formed between the skin surfaces.
5. When there are wounds involving all the fingers, dress the fingers separately to prevent adhesions between them.
PRINCIPLES INVOLVED IN THE CARE OF WOUNDS.
Purpose:
1. Micro-organisms are present in the environment, on the articles and on the skin. Pathogenic organisms are transmitted from the source to the new host directly or indirectly.
Nursing Action:
1. Anything that touches the wound should be sterile e.g., dressings, instruments, solutions.
2. Emphasize on hand washing before and after the procedure.
3. Observe strictly the principles of surgical asepsis.
4. The wound and the surrounding skin should be cleaned thoroughly to reduce the number of bacteria.
5. The wounds should be protected always with clean and sterile dressings.
6. Removal and replacement of the dressings should be done when the air movement is at minimum. (no sweeping should be done when the dressings are opened).
7. The soiled dressings should be carefully collected and burned to prevent the spread of infection.
8. The contaminated articles should be disinfected before it is used again.
9. Keep the environment free from dust and flies.
10. Practice barrier nursing. Isolate patients with clean wounds from those patients with contaminated wounds. Use of gloves, masks and gowns increases the barriers to the organisms.
2. Bacteria travel along with the dust particles.
Nursing Action:
1. Sweepings and dustings should not be done when the dressings are in progress. It should be done at least one hour before the expected time of the dressing.
2. Flappings of the bed cloths and dresses should be avoided to prevent dust particles entering the wound.
3. Sterile articles must be kept covered until it is time for use. Prolonged exposure to the air makes them contaminated.
3. Cleaning an area where there is less number of organisms, before cleaning an area where there are more organisms, minimize the spread of organisms to the clean area.
Nursing Actions:
1. Consider the wound area cleaner than the skin around even if the wound is infected.
2. Keeping this principle in mind, clean the wound from the centre to the periphery, discarding the used swab after each stroke.
3. Skin and mucus membranes normally harbor pathogens. If the wound is cleaned of the skin around the wound, there is less chance of introducing the skin pathogens into the wound.
4. A break in the skin and mucus membrane acts as the portal of entry for the pathogenic organisms.
Nursing Actions:
1. Open wounds are to be sealed or dressed as early as possible to prevent the entrance of pathogenic organisms into the body.
2. All precautions are to be taken to prevent further tissue damage and promote the healing process.
3. Use antiseptic solutions of correct strength which are safe for the skin and mucus membranes. Using this antiseptics of high concentration can cause tissue damage.
4. When using the heat in the form hot fomentation or surgical soak, the temperature should be controlled between 37 to 40.5 degree Celcius to prevent tissue burns.
5. Respiratory tract harbours micro-organisms that can enter the wound.
Nursing Actions:
1. When dressing large open wounds, masks may be worn by the nurses to prevent the organisms entering the wound through the droplets.
2. Avoid talking, coughing and sneezing while attending to a wound.
6. Nutrients and oxygen are carried to the wound via blood stream and are essential for collagen formation.
Nursing Actions:
1. Avoid constrictive bandages that reduce the blood supply . to the area.
2. Take plenty of fluids to prevent dehydration.
3. Correct anemia, if present, to promote healing process.
4. Use gravity to reduce the venous congestion.
5. When applying bandages, begin distally and move proximally along the venous return.
7. Moisture facilitates growth and movement of microorganisms.
Nursing Actions:
1. Microbes can neither live nor travel without moisture. Therefore keep the sterile field dry.
2. Replace the soiled dressing with dry dressings as soon as they are wet. Otherwise the microbes can enter the wound by travelling through the wet dressings.
8. Fluid moves downwards as a result of gravitational pull.
Nursing Actions:
1. Anticipate the drainage at the lower edge of the wound. Therefore enforce dressings at the lower edge of the wound to collect the drainage.
2. When the drainage tubes are to be put, they are placed at the lower edge of the wound.
3. When there is oedema of the injured part, it should be raised above the heart level.
9. Fluids move through materials by capillary action.
Nursing Actions:
1. Cotton and gauze dressings when applied over the wounds, absorb the drainage from the wounds and keep them dry.
2. Bacteria are carried by capillary action along with the fluid, from the unsterile surface to the dressings, if the dressings are wet.
10. Unfamiliar situations produce anxiety.
Nursing Actions:
1. An adequate explanation of the treatment will help the patient to know what is to be expected. This will reduce the fear and anxiety.
2. Maintain the privacy of the patient and avoid unnecessary exposure.
3. Do not expose the wound in front of the patient. Turn the patient’s head to one side to avoid unpleasant sight.
4. Diversion of mind is provided by conversation or by other means.
5. The nurse should try to control her reactions at the sight of the wound or dressing. The patient frequently studies the face of person changing the dressing in order to evaluate the extent of injury or healing process.
11. Systematic ways of working saves time, energy and material.
Nursing Actions:
1. Place the bed and the patient working height.
2. Prepare the patient, articles and the environment before the dressings are opened.
3. Assemble and arrange the articles on the bedside locker conveniently to avoid leaving the patient in between the procedure.
4. Protect the personal clothing and the bed linen with a waterproof covering.
5. Get assistance if needed.
NURSING DIAGNOSIS RELATED TO WOUND HEALING
Impaired skin integrity related to
Surgical incision
Pressure
Chemical injury
Secretions and excretions.
High risk for impaired skin integrity related to
Physical immobilization
Exposure to secretions.
High risk for infection related to
Malnutrition
Tissue loss and increased environmental exposure
Acute pain related to
Abdominal incision
Impaired physical mobility related to
Pain of surgical wound
Altered nutrition: less than body requirements related to
Inability to digest food
Infective breathing pattern related to
Pain of abdominal incision
Altered tissue perfusion related to
Interruption of arterial flow
Interruption of venous flow
Disturbance in self-esteem related to
Perception of scars
Perception of surgical drains
Reaction to surgically removed part
