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Файл:Clinical nursing practice. Study aid for foreign students of medical university
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Traditional wound care. Traditional methods and experimentally
supported theories often offer conflicting advice. Traditional care teaches
that wounds should be kept clean and dry to prevent infection, although
this delays healing and gives poor cosmetic results. Antiseptics are used
both to prepare the site and clean the wound and dryness is maintained
with a dry dressing or by exposure to the air. When wounds involve tissue
loss, packing prevents closure at the surface before the crater is filled.
Packing materials may be gauze impregnated with antiseptics, non-adherent
preparations such as petroleum jelly, or a variety of foams, gels and
polymers.
Research-based wound care. By contrast, research-based wound heal-
ing has established that there is an acceleration of the inflammatory and
proliferative phases of wound healing in moist conditions, compared to dry
conditions. A moist, warm environment, as created beneath a semi-permeable
membrane, allows optimal conditions for the re-epithelialization of surface
wounds. The nourishment provided by plasma leaking into the wound base
has been mimicked by the use of protein-containing nutrient solutions.
Both situations in essence provide an environment for tissue growth, particularly where wounds are clean (there may be limitations in relation to
some patients/clients and some wounds, for example, in a person with an
infection, there is a danger that the infecting organism will enjoy the nutrient medium as much as the patient/client's own cells).
At first these theories may seem to be at two extremes, but it is important to realize that both add to our understanding of the conditions for
wound healing and both are of use in assessing and managing different
wounds in different settings.
Wound care practice.
Assessing and reporting on wounds. Replacing wound dressings is a
nursing responsibility. At the dressing change, the nurse's assessment of
the wound and reporting of its condition are important (see tab. 7). If reporting is poor, the wound dressing may need to be removed for verification of the condition, which adds to the risk of infection.
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Table 7
Assessing and reporting on wounds
Factor to assess
Variables
General
Underlying cause; location; presence of hematoma, seroma
or edema; amount of necrosis; open/closed; frequency
of dressing change required over time
Pain
Amount: at change of dressing, only when traumatized,
intermittent, continuous, time of day, type of pain
(sharp, stabbing, dull, etc.)
Stage of healing
Original tissue loss, amount of granulation and epithelial tissue,
area/volume/depth of wound, temperature, sensation,
inflammation
Drainage
Color, consistency, nature/type, volume over time, odor
Area surrounding
the wound
Color, edema, erythema, sensation, turgor, other skin conditions
Infection
Amount of pus, pain, temperature, positive swab culture,
inflammation
Wound cleaning. The rationale for wound cleaning is to help create
the optimum local condition for wound healing by removal of:
• Excess debris.
• Exudate.
• Foreign and necrotic material.
• Toxic components.
• The food source of potential infecting micro-organisms.
• Bacteria and other micro-organisms.
Cleansing solutions. A number of solutions have traditionally been
used to clean wounds, some of which need to be used with caution as they
have been found to have potentially harmful local or systemic effects. Table 8 summarizes current recommendations of the suitability of different
products used on wounds.
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Table 8
Products used on wounds
Solution
Suitability
Comments
Sodium Chloride (0,9 %)
Suitable
Used at body temperature it is the safest
and most effective cleansing solution for
non-contaminated wounds. Although
it has no antiseptic properties, it dilutes
bacteria and is non-toxic to tissue
Chlorhexidine
Not ideal,
use with caution
Antiseptic — can cause sensitization and
irritation. Do not use alcoholic solutions
Hydrogen peroxide
Not ideal,
use with caution
Antiseptic - use on dirty, infected,
necrotic wounds only; may be caustic
to skin/wound; do not use on large
or deep wounds as it may cause air
embolism
Metronidazole
Not ideal,
use with caution
Antibacterial (to anaerobes only) — can
cause nausea
Povidine-iodine d %
Not ideal,
use with caution
Antiseptic — do not use alcoholic
solution; can occasionally cause skin
reactions; possibility of systemic
absorption, some sources suggest that
it should not be used on severe
or extensive bums, if non-toxic goiter
is present, in pregnancy, or in lactating
women
Boric acid
Not suitable
Bactericidal — toxic to tissues, fatal
poisoning
Ceramide
Not suitable
Antibacterial and anti fungal — toxic
to wound tissues and causes skin
hypersensitivity
Gentian violet
Not suitable
Astringent, antiseptic — carcinogenic;
is sometimes used on excoriating
radiotherapy bums
Mercurochrome
Not suitable
Weak bacteriostatic agent — toxic
to tissue. (Continues on the next page)
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Solution
Suitability
Comments
Sodium hypochlorite
Not suitable
Antiseptic — powerful oxidizing agent
which is toxic to tissue. Experimental
research has found that hypochlorite
solutions stop blood flow in capillaries,
delay the production of collagen and
delay the inflammatory response
in open wounds
Wound coverings. Healing progresses most rapidly if the wound can
be closed. When there is considerable tissue loss, this must be filled before
the surface can heal. In theory, closed wounds need no covering, while
open wounds need some. David suggests any of the following are good
reasons for covering a wound:
• Protection (from friction, dehydration, infection).
• Enhancement of healing by providing a moist environment.
• Aesthetic factors (to prevent the patient being distressed by the
wound).
• To achieve immobilization or positioning of the wound (to opti-
mize the speed of healing or to prevent deformity).
• Reduction of pain.
• Application of chemicals (to feed growing cells, loosen or debride
dead tissue or to treat infection).
• Reduction of odor.
• Compression (to prevent hematoma, or a hypertrophic scar).
Is there an ideal wound dressing?
Generally, an ideal wound dressing is described as one which
“...applied to the surface of a wound, provides and maintains an environment in which healing can take place at the maximum rate”.
Most sources suggest that in order to provide an optimum healing
environment, a dressing must fulfil a range of criteria.
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Criteria for an ideal dressing:
• Remove excess exudate and toxic components.
• Maintain a high humidity at the wound dressing interface.
• Allow gaseous exchange.
• Provide thermal insulation.
• Be impermeable to bacteria.
• Be free from particulate or toxic components.
• Allow change without trauma.
• Minimize pain.
• Minimize odor.
• Minimize bleeding.
• Be comfortable and acceptable to the patient/client.
• Be cost-effective (in the long term).
No single dressing can meet all of these criteria in any or all situations. The best dressing in a given situation is the one which meets the
most important criteria for a particular wound and which it is realistic to
use in terms of the patient or client and any resource implications. Some
dressings (such as occlusive dressings) achieve many of the criteria but are
not suitable for all wounds. Others may achieve fewer of the criteria but
may be the only alternative acceptable to the patient/client. Increasingly,
cost considerations are a major influencing factor, limiting choice at several levels.
Given the individual nature of every wound, the vast array of dressings manufactured and the reality of limited resources and practical constraints, it is neither possible nor appropriate to try to describe here which
dressing is most suitable. Rather the principles and criteria are offered as
an aid to critical thinking and to encourage practice based on a sound
knowledge base.
How often is a dressing needed?
Generally the principle is one of minimum disturbance of a wound.
Care should be planned and rationalized in order to prevent unnecessary
intervention. Where dressings are undertaken, they should be carried out
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with the minimum disruption to the healing wound. Reasons for disturbing
a wound are:
• To observe the wound for complications.
• To remove excess exudate.
• To remove dead tissue.
• To remove drains or sutures.
• To treat local infection.
• Clinical nursing procedure guidelines: Changing wound dressings.
• Equipment.
• As for “Guidelines: aseptic technique” (section 5.2).
• Cleansing fluid for irrigation.
• Appropriate dressing.
Procedure. See procedure for “Aseptic technique” (section 5.2) up
to and including step 10, then as follows:
Action
Rationale
11. Where appropriate,
loosen the previous dressing
The dressing can then be lifted without
causing trauma. The time the wound
is exposed should be kept to a minimum
to reduce the risk of contamination and
to minimize any drop in the wound
temperature. A fall in the temperature
of the wound of 12 °C is possible if the
procedure is prolonged or lotions are
cold. This can take three hours or longer
to return to normal warmth, during which
time cellular activity is reduced and the
healing process slowed
12. Wash hands (or preferably clean
hands with a bactericidal alcohol rub,
where available)
Hands may become contaminated
by handling outer packets, previous
dressing, etc.
13. Using the forceps in the pack, arrange
the sterile field with the handles
of the instruments in one comer or around
the edge of the sterile field. Where
To minimize the risk of contamination
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Action
Rationale
appropriate, swab along the “tear area”
of lotion sachets with chlorhexidine
gluconate 0,5 % and isopropyl alcohol
70 %. Tear open sachet and pour lotion
into gallipots or an indented plastic tray
14. Remove dressing with one pair
of forceps (which should then
be discarded) or by placing a hand
in a clean, clear plastic bag, lifting the
dressing off and inverting the plastic bag
so that the dressing is inside the bag. The
bag is then used as the “dirty” bag for the
procedure. Take care to ensure that when
removing the previous dressing, the
wound is not touched and thereby
contaminated
To reduce the risk of cross infection
15. Attach the bag with the soiled
dressing inside to the side of the trolley,
below the level of the top shelf
Contaminated material is below the level
of the sterile field
16. Assess the wound healing (see Table
7) with regard to: pain; stage of healing;
drainage; the surrounding tissue; signs
of infection. (Record the assessment
in the relevant documentation at the end
of the procedure)
To evaluate wound care. The wound
should be evaluated each time a dressing
is applied, or if there is cause for concern.
The aim of evaluating the wound
is to assess healing and establish which
treatment will best provide the ideal
environment for healing.
17. Put on gloves (if available), touching
only the inside wrist end
To reduce the risk of infection to the
wound and contamination of the nurse.
Gloves provide better sensitivity than
forceps and are less likely to traumatize
the wound or the patient/client's skin
18. If necessary, gently cleanse the
wound with a gloved hand using 0,9 %
sodium chloride (unless another solution
is indicated) and non-lining material,
To reduce the possibility of physical and
chemical trauma to granulation and
epithelial tissue. If a wound is clean and
little exudate is present, repeated cleaning
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Action
Rationale
such as foam. If appropriate, irrigate
by flushing with water or 0,9 % sodium
chloride
is contraindicated as it may damage new
tissue, decrease the temperature of the
wound unnecessarily and remove exudate
conducive to healing. Cotton wool
or gauze used in cleaning can leave fibers
in the wound. This may stimulate foreign
body reaction and lengthen the
inflammatory phase, which can retard
wound healing, damage new epidermis
and act as a focus for infection.
If necrotic tissue is present, debridement
is necessary as this can interfere with
healing and increase the risk
of wound infection
19. Apply the most suitable dressing for
the wound, using the criteria for an ideal
dressing (see Table 9)
To promote wound healing
20. Remove gloves and secure the
dressing as appropriate
Continue with steps 15 to 19 from the guidelines for “Aseptic
technique”.
Wound care in the community. Community nurses need to be resource fill in order to translate the principles of asepsis and wound care to
clients' home environments. A community nurse may have to accept conditions which are less than ideal, to gain the compliance of a client.
David recalls one colleague who undertook a regular leg ulcer dressing with the client supported on fruit boxes behind his market stall. The
client would agree to regular treatment only if he was able to continue his
regular “watch” of his son's business. In this way, the wound was successfully treated and healed, where other nurses who had insisted he was treated at home had failed.
Traditionally, the majority of people cared for in the community have
been elderly and their problems long-standing. But as health care changes
and technological advances mean shorter hospital stays for many people,
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the demands on community nurses’ expertise are growing ever more complex. People are discharged home much earlier and with more technical
health care needs than previously. Many dressings may now be undertaken
by the patient/client themselves or their family members. The role of the
community nurse in this case is to provide advice, support and teaching in
relation to wound care; to ensure that supplies of equipment and dressings
are maintained and to evaluate wound healing and the effectiveness or otherwise of planned wound care with the person.
For the community nurse, there is an even greater responsibility for
assessing, planning, implementing and evaluating care without direct peer
group consultation. The great advantage of community nursing is that continuity of caregivers is maintained often over the entire time that a wound
needs for healing.
David suggests that the main aims of treatment planning are:
• The overall care of the person, rather than treating the wound in
isolation.
• The specific care of the wound.
• Teaching and supporting the person in relation to self-care.
• Realistic goal-setting; this may, for example, be the maintenance
of a clean stable wound for someone who is terminally ill.
• Ideal healing and a good resulting scar.
Visits from a community nurse can represent intensive periods of
skilled treatment and teaching for the client and their relatives or other carers. The visits are also an opportunity to assess the need to involve other
services, such as physiotherapy, occupational therapy and dietary advice,
which are usually not so readily available to the community nurse, as they
are in the hospital setting.
Adapting the dressing technique. Working in people's homes means
working alone and having to think creatively in order to adapt techniques,
usually learned first in a hospital setting, to a wide variety of different circumstances. The reasons for using an aseptic dressing technique apply just
as much in the person's home as in hospital. The environment in which the
dressing is done should be free from contamination and the principles of
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preventing infection need to be maintained. The instruments and equipment used for dressing must be sterile. The home environment may present
practical difficulties for some treatments — the availability of hot water
and suitable containers for soaking wounds, for example, a suitable surface
for equipment, or adequate lighting. The position of the community nurse
as a “guest” in the person's home means that considerable tact may be required to achieve the best solution to problems with the environment. Sometimes it is important to be able to accept what is less than ideal in order to
be able to work with the client and his or her family.
Hand washing may sometimes prove difficult, so disinfectant — impregnated tissues or proprietary solutions are often essentials.
Antiseptics may be needed to sterilize reusable instruments. As in the
hospital, cross infection may be avoided by visiting clients according to
their wound status, so that clients with “clean” wounds are visited before
those with “dirty” wounds.
Safe disposal of waste is particularly important in the home. The ideal method is to bum any soiled dressing materials immediately. If there is
no open fire, there is no realistic alternative to the client's refuse bin. In
this case, disposable instruments should be broken up to prevent re-use and
be well wrapped and sealed before disposal. If there are problems with
safe disposal of waste, it may be necessary to take the waste away for disposal in an appropriate place or to make special arrangements with an environmental health service.
Adapting the dressing. For wounds such as bums or hand or foot injuries, adaptations of dressings and the way of securing them, may help increase the person's independence for many activities in which they would
otherwise be limited. For example, occlusive dressings can be used for
bums or to provide waterproof dressings for hand or foot injuries. For people with hand injuries, a polythene (cling) cover, or plastic gloves will protect the dressing during washing.
Self-care. Many people are capable of self-care, or may be treated by
relatives or friends. This is especially useful when a dressing needs fre-
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