By Martin Vera, LVN, CWS
Throughout my career I have been lucky enough to be part of several nursing branches: home health, long-term care, acute care, long-term acute care hospital, hospice, and even a tuberculosis hospital; wounds have no limitations on where they will appear. As a passionate clinician, teaching, coaching, and mentoring have become a huge part of what I do, as is true for most clinicians. We are teachers, coaches, and mentors driven by passion and wanting to help and put in our “two clinical cents” or “stamp” on the industry.
I frequently converse with clinicians in my area, all part of SWAT (skin and wound assessment team), and talk about how it takes a village. I especially enjoy talking with my good friend and mentor Jesse Cantu, RN, BSN, CWS, FACCWS, who is a passionate clinician with a fire that gets you all excited—those who know him know what I am talking about. We share stories of what we do, we give each other constructive criticism, and we often share with each other some of the most common inadequacies we see out there. We always get after each other, in a good way: are we doing enough? and how can we help educate, empower, increase awareness, and give health care clinicians the tools necessary to be successful?
In this blog, I share with you common inadequacies seen in the different settings of wound management nursing and the tools necessary to correct them and be successful.
Seasoned clinicians often push ourselves and those around us to improve our skills. Most of us use common clichés—that are so true, by the way—like “Look at the whole patient, not just the hole in the patient” or “The only donuts we care about are jelly filled.” When someone approaches us with a wound question, one of the first things I ask is location, location, location. Where is the wound, what are the patient’s comorbidities, is he or she diabetic, or hypertensive, or has an inflammatory disease; what are his or her medications, nutrition, hydration, etc.? We want to paint the best picture of the patient possible to even be able to make some type of an educated guess.
It takes much discipline and dedication for a clinician to embrace wound management and be able to grasp the different types of wounds and classify them correctly. It takes practice, consistency, and devotion, and it doesn’t happen overnight, either, but here are some steps to take to get the most of your initial assessment.
Obtain a thorough health and physical examination (H&P)—it matters. Does the patient smoke, drink, use alcohol, have a history of intravenous drug use? What is the patient’s past medical history? Does the patient have diabetes mellitus, hypertension, sickle cell anemia, or any other disease pertinent to overall care? What is the duration of the wound (chronic or acute), history of recurrence, history of venous or arterial insufficiency, classification of wound by degree of extent of tissue damage (partial- or full-thickness), correct anatomical position to include to correct the affected site, leg, arm, over a bony prominence? Measure the size of the wound using an appropriate method (e.g., L × W × D and using centimeters).
What is the appearance of the wound bed (granular, necrotic, slough, epithelium) and periwound tissue as well, wound edges (attached, unattached, inflamed, calloused, epibole, macerated), drainage (scant, minimal, moderate, heavy, serous, serosanguineous, purulent, sanguineous), temperature of wound as compared with adjacent tissue, pain management? A proper H&P, as discussed earlier, will allow clinicians to identify barriers and prepare how to manage the wound. Identifying classification allows for better treatment options, and as a result, proper documentation will follow.
Far too often, I have come across orders of “cleanse wound with normal saline and pat dry with gauze” during rounds or while educating a clinician new to wound management. I will see a nurse open 4×4 gauze, pour saline on the wound, and use the gauze to cleanse or dab the wound, open another packet of gauze, and pat dry.
All wounds have surface bacteria. All chronic wounds are contaminated, and therefore using the correct psi (pound per square inch) in wound cleansing or irrigation plays a big role in wound management. The goal of irrigation is to be able to remove bacteria and debris safely from the wound without injuring good tissue.
Current standards indicate that wounds should be irrigated or cleansed with 4–15 psi. Normal saline continues to be the most physiologically compatible solution and most widely used. The use of a 19g angiocatheter with a 30mL syringe filled with saline at four to six inches away from the wound should deliver around 8 psi, within range to accomplish the goal. When using wound cleansers, just consider the type of wound cleanser, and make sure to deliver psi within the acceptable range of the goal and standard.
Although several methods of debridement are available, it’s the use of the SWAT team and proper assessment that will allow us to make the best recommendation based on individualized patients’ needs.
Debridement refers to the removal of necrotic or non-viable tissue to allow healthy tissue to fill deficit with granular tissue and re-epithelialize. Currently, we have the options for autolytic, enzymatic, mechanical, sharp, surgical, and larval or maggot debridement therapy (MDT).
The proper assessment and classification of the wound and underlying factors will be able to guide clinicians and practitioners to the appropriate type of debridement to meet the patient’s needs. Is the patient taking blood thinners? If so, then sharp or surgical debridement may not be the immediate choice. If the patient cannot tolerate surgical debridement for whatever medical reason, then maybe a combination or conservative sharp and enzymatic may be the best choice. Also, some of the advanced wound care products help in facilitating autolytic debridement. Closely identify and manage barriers, consider medications taken, discuss with the SWAT team, discuss with patient and family to keep them abreast, and take into consideration their input. Once the goal has been achieved or getting close to it, re-assess and discuss with the team to start making recommendations as the wound is being pushed out of inflammatory phase into the proliferative phase of wound healing.
Inadequate Dressing Selection
Moist wound healing has been the standard for wound healing since being implemented in the 1960s by Dr. G. D. Winters. For dressing selection, we rely again on our proper assessment and keep an eagle eye out for allergies, composition of dressings, adhesives, and even latex allergies. With the thousands of wound care dressings out in the industry, I can see how it can become a huge challenge to find the right dressing. How do we manage to “dress for success?”
Wounds evolve as we treat them. We take them from the inflammatory phase with the use of debridement, antimicrobial dressings, managing heavy exudate, and finding the right combination of treatment and dressing strategies. Then we send them to the proliferative phase of wound healing, and now the needs of the wound have changed. What dressing do we use to maintain a moist healing environment, manage the current amount of drainage or exudate, and address bacterial burden? Clinicians must go through the daunting process of choosing the right dressing, avoiding maceration and desiccation, and avoiding pain and discomfort–all of which delay wound healing.
As a wound evolves, that heavily draining wound is now drying up with use of alginate; or perhaps the periwound tissue becomes macerated or denuded. Assessment of wounds must be done with every dressing change. Efficacy of treatment must be ascertained at least every two weeks or as indicated by your policy and procedures. This allows us clinicians to use our TIME principle of wound bed preparation: looking at the tissue, infection/inflammation, moisture balance or imbalance, and edges of the wound. Using this platform will guide clinicians in making the correct decision and the appropriate recommendation based on the current needs of the wound. Continue to assess with every dressing change and re-evaluate every two weeks. Wound healing is expected at 20% to 40% in two to four weeks. Manage barriers, consult with SWAT, and continue making recommendations based on standards of care, best practices, and evidence-based research. We need to be cost effective and achieve positive outcomes.
Inadequate Pain Management
Pain remains a huge factor in wound management. That is why it’s very important to assess pain correctly to be able to effectively create the proper plan of care that promotes wound healing. Research indicates when pain is not properly controlled, our body overproduces inflammatory enzymes and cytokines that become a barrier to healing. Wounds cause pain and anxiety, affect moods, and depress some of our patients because they feel hopeless, and quality of life decreases. Clinicians help with this issue. A correctly performed pain assessment (vital for creating an effective plan of care) and use of a SWAT team may reveal that the patient needs a pain specialist to help properly manage pain.
The benefits of pain reduction can improve healing rates and ultimately a patient's quality of life. It is the clinician's moral and ethical responsibility to be professionally competent in the most appropriate approaches to managing pain to improve a patient’s overall care. As mentioned in the section on dressing selection, clinicians have the responsibility to choose not only the dressing that will follow the moist wound healing standard, but also one that causes minimal pain or discomfort.
In closing, education remains key. Challenging ourselves and our colleagues in improving our assessment skills or finding ways to be more effective with our patients will be greatly rewarded. In my world, four eyes and better than two, and two heads are better than one— the more the merrier.
I encourage you to keep in touch with the wound specialist in your area, challenge each other, discuss ways to improve yourself and others. Remember, as clinicians, we have a duty to coach, teach, and mentor. How can you improve yourself and possibly your community? Always follow standards of care, evidenced-based research, best practices, and be cost effective in order to achieve positive outcomes. Consult to your company’s policy and procedures always.
Keep healing, my friends!
Bechert K, Abraham SE. Pain management and wound care. J Am Col Certif Wound Spec. 2009;1(2):65–71.
Hess C. Clinical Guide Wound Care, 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2002.
Shah JB, Sheffield PJ, Fife CE, editors. Wound Care Certification Study Guide, 2nd ed. North Palm Beach, FL: Best Publishing; 2016.
About the Author
Martin Vera is a certified wound specialist with over 20 years of nursing experience, with a passion for wound management and patient-centered care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.