Wounds

Nursing Care for Wounds-A Student’s Guide

Introduction

The first step in wound care is to identify the type of injury. A wound’s classification determines how it should be cared for and when a patient should contact their healthcare provider.

There are two categories of classification of wounds. The first classification is as follows: clean, contaminated, infected, necrotizing (also known as “Munich”), and delayed primary closure.

The second classification includes deep wound, shallow wound, partial thickness, full-thickness, and skin only.

This article is meant to guide nursing students through the process of wound care. As you read, keep it in mind that our top writers are ready to help in case you get stuck with your nursing assignment or can’t complete it due to reasons such as a busy schedule. All you need to do is place an order with us!

Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Identifying the Type of Wound

Wounds are usually identified by location, size, and specific characteristics.

Location: Where was the wound located? The most commonly known areas are the face, neck, trunk (chest, back), extremities (hand bitten off or foot).

Obstructed Wounds: This type of wound has been impeded from normal healing; these wounds are usually at high risk of infection. Obstruction can occur from foreign objects (i.e., broken glass or a piece of wood in an open wound), clothing wrapped too tightly around the area, and severe swelling due to inflammation, trauma, or crush injuries.

Clean wounds

These are wounds that have been treated and drained properly. They are not covered with any foreign objects, and they are free of contamination.

Contaminated wounds

These wounds get infected easily; the skin may also be pierced by a foreign object (i.e., needle or knife), or there is still debris in the wound, which can cause infections. The most common type of wound that is classified as contaminated includes the following:

-Skin wounds caused by piercing objects such as hypodermic needles, nails, knives, or insect bites.

-Pathological wounds; are puncture wounds caused by sharp bones such as femur fractures.

-Arterial injuries; are open wounds in a cross-section of an artery.

Diabetic foot ulcers, post vein thrombosis, and decubitus ulcers.

There are two types of pathological or contaminated wounds including:

1) Clean but non-healing wound problems such as infection, cancerous tumors, if the patient has been immobilized for a long time, or even poor blood supply.

2) Improper wound care to start with, like when the patient does not clean their wounds properly.

Infected Wounds

The body’s immune system plays an important role in keeping people from getting infected; however, there are some cases where the body’s immune system is weakened and cannot control the infection from taking over.

When the body immunity is weakened, an infection or wounds that are contaminated/ infected occur.

Necrotizing (Munich) wounds

These wounds are caused by a lack of blood flow to the region where it is located.

It can be caused by cancerous tumors or infection, arterial insufficiency, thrombosis, and poor nutrition. It usually starts from the end of the extremity and can extend throughout the entire limb if not treated properly.

Delayed Primary closure

These types of wounds are extensive and severe. They occur due to crushing injuries, loss of limbs, or skin infection, making it impossible for surgeons to close the wound after extracting the foreign objects.

Deep Wound

This wound goes through more than one layer of tissue, such as subcutaneous fat (under the skin) and muscles.

Shallow wound

This type of wound only penetrates the epidermis or the first layer of skin (i.e., scrapes and scratches). Minor lacerations, abrasions, and contusions are all considered shallow wounds by medical professionals. This is a term used to describe wounds that do not go through the full thickness of the skin.

Partial-thickness and full-thickness wounds

Partial-thickness wounds are wounds that go through the skin, fat, and muscle but do not go deep enough to reach the bone.

Deep wounds, also known as full-thickness wounds, are those large wounds with damage or tissue loss below the first layer of skin. This type of wound can be caused by accidents (i.e., car crashes, gunshot wounds), dog or cat bite wounds. They can also be caused by surgical incisions and lacerations sustained during a fight; they are usually referred to as stab wounds.

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Nursing Care for Wounds

With all the different types of wounds mentioned above, nursing care for these individuals depends on the type of damaged tissue that needs care. Medical professionals should consider the type of tissue that has been damaged and the type of wound it is since this will determine how they should care for their patient’s injuries.

Hand Wound Care

Wounds on certain body parts such as those located on the hand should be treated differently than other types of wounds such as leg or arm wounds.

When treating a wound on the hand, nurses need to know how to treat hand infections and tell when there are signs of infections in the wound area.

Hand wounds should be treated with extreme care by medical professionals because if they are not, patients may have problems performing daily functions such as eating and may be at risk of having respiratory issues.

Since hand wounds are located on the most active part of your body, those wounded in that area might find it difficult to move even when their injury is not that severe.

Medical professionals need to treat these wounds with extreme care, not to cause any further damage to surrounding tissues. Hand wounds should be treated properly and with a lot of tender loving care because it is the most active part of your body.

Minor Wound Care

When treating minor wounds, nurses need to have the right supplies they need to complete their tasks. Nurses must also know how to clean, suture, and dress minor injuries so as not to cause any further infections in the wound area.

Nurses need to know how to treat minor wounds and their surrounding areas properly. A superficial cut can become infected or lead patients to develop other conditions such as gangrene, necrosis, and sepsis.

Wound Dressings

There are different wound dressings such as gauze, bandages, and special dressings used for specific wounds.

The perfect type of dressing should allow the wound to breathe and protect it from surrounding irritants. The proper dressing can help with the healing process by keeping out foreign particles that could harm the wounded area.

Nursing wound assessment

When assessing a wound, it is important to know what type of tissue is damaged. This will help nurses properly care for their patients and prevent them from getting other infections from outside sources.

Wound assessment includes:

  1. Looking for areas of pain or sensitivity.
  2. Checking the edges of the wound for signs of redness, swelling, and drainage. Looking closely at the puncture site will help nurses know if they should look deeper or not.
  3. Looking closely at the skin around the injured area to see if it is broken or intact. This can help them determine how best to clean and dress wounds.
  4. Assessing the sensation in the area. This will help nurses know if there is a loss of feeling or not. Nerves can be damaged when certain wounds are inflicted on patients; this can affect their daily activities.
  5. Assessing the wound area for deformities, including but not limited to: Discoloration– Due to the presence of redness and other colors around the wound area. Hole– This is a hole in your skin caused by injury, disease, or surgery. Bump– This can happen when you have an excessive amount of swelling due to excess fluid build-up around the wound area

Nursing wound management

When caring for wounds, it is essential to know what kind of shape the injury is in.

Using knowledge from wound assessment, nurses can identify possible problems and how they should approach their patient’s care. A couple of things that nurses must be careful about when treating patients are allergic reactions to certain medications and patient safety.

Wound care nursing management includes:

  • Determining the best way to clean your wound. Your nurse will assess what type of care you need based on their findings during an assessment. After deciding what kind of cleaning method is necessary, they place it on the wound and remove any debris or other substances found within the wound.
  • Applying medication when needed. This can help with pain and prevent any risk of infection or any other side effects from occurring.
  • Placing dressings on the wound area to help it heal faster, keep out bacteria, and potentially prevent your wound from becoming infected. Dressings are not meant to cure your wounds but treat them by keeping them clean and providing a protective covering.
  • Wound debridement is when a nurse removes dead or damaged tissues containing bacteria and other infectious materials that could lead to further infections within the wound area.
  • When treating wounds, nurses need to make sure they are using the right supplies and clean them with the appropriate chemicals not to cause any further complications or damage to the patients.
  • To care for your wound properly, patient education is essential between you and your nurse. Before being placed on wound care, your nurse will educate you on what to expect from the treatment and how you can keep yourself safe. This includes any risks associated with your treatments and side effects that may occur throughout each stage of recovery.

Wound Care Goals

This process aims to eliminate contamination, provide protection, and promote healing by providing nutrition to the cells that make up your body.

The goals for wound care are:

1). To remove as much bacteria as possible from the wound- A wound that has been infected with bacteria develops an infection, which can lead to the development of deadly diseases.

Antibiotics can be used to kill off bacteria that make their way into your wound. Keeping it clean and applying dressings will help keep out any further threats of infection.

2). To protect the wound healing cells– Proper dressings help keep these cells protected in the process of recovery, which decreases the chances of them being damaged or removed from the body.

3). To control odor– The nurse has to make sure that the wound does not contain any scent, which could be a sign of infection or other complications. Frequent cleaning of the injury, changing the dressings, and applying medication when needed helps decrease the smell.

4). To control bleeding– If a patient is losing blood at an alarming rate, it may take a severe toll on the body even if they have been provided proper treatment. If this happens, then there is less time for the healing process to work. The nurse must ensure that bleeding is stopped before it can cause any problems.

5). Ensure correct moisture level– Properly moisturized wounds heal faster, keep the wounds from being irritated and dry, and decrease the risk of infection. In case of a dry wound, the nurse must moisturize the area because it is more susceptible to disease. Moisture levels must be monitored so proper care may be provided.

6). Control pain- The presence of pain can cause the patient to be less cooperative and have a hard time healing. Nurses must manage pressure points and decrease pain to prevent this response from occurring.

7). To promote tissue growth– The best way for healthy cells to grow rapidly is through nutrition, so good nutrients must be provided to the cells. If a patient has been prescribed any vitamins or minerals, it’s the nurse’s job to ensure that they are taken regularly for the wound to heal properly. The best way for healthy cells to grow rapidly is through nutrition, so good nutrients must be provided.

8). To promote wound contraction– When a wound is healed, it must be able to shrink back into its proper place. Nurses can make sure that the skin around the wound does not contract too tightly, which could cause pain or restriction of movement.

9). To help maintain sterility in the area– Wounds are usually a breeding ground for bacteria, so proper measures must be taken to ensure that the wound does not become infected.

Step by Step Process of Wound Care

1). Incise or debride the wound– The first thing that a wound needs is to be cleaned off. This process, known as incision and debridement, involves cutting away unhealthy tissue from a wound to grow healthy tissue. Most of the time, this is only used in cases where there are loose dead tissues.

2). Irrigate the wound with saline– This process is performed by filling a syringe with an isotonic solution and flushing it through the wound to help get rid of any foreign substances or waste that may be present. It’s extremely important because bacteria can often be found in the deepest parts of a wound that are hard to reach, even with a disinfectant.

3). Clean the wound– The nurse cleans the wound using swabs and cotton balls soaked in saline solution or an antiseptic solution. After this is done, the nurse’s hands are thoroughly washed to be no risk of cross-infection.

4). Dress the wound– The nurse puts a dressing on the wound by ensuring that the surrounding skin is covered to prevent any infection, controlling odor and blood flow.

5). Monitor the wound– The process for monitoring wounds includes checking temperature, redness, and drainage every 4 hours for 24 hours, then once a day until healed. If there are no signs of infection, then the process is extended to less frequent visits.

6). Provide pain relief– If pain relief has been prescribed for a wound, then it must be taken during each visit to ensure that the patient isn’t suffering unnecessarily while they heal.

7). Provide nutritional support– If a patient is prescribed specific vitamins or nutrients, then the nurse makes sure that they are taken regularly to promote healing.

8). Monitor tissue reaction– Wounds often have adverse reactions to their environment, such as allergic reactions. Allergic reactions can be found by evaluating wounds for size, color, temperature, and drainage.

9). Maintain sterility– To prevent infection from occurring, wounds are covered in a sterile dressing that prevents bacteria or other foreign contaminants from entering the wound. The dressing must stay on until the wound is healed and be cleaned every 4 hours with a new dressing being applied.1

10). Promote wound contraction– Wound care nurses need to make sure that the skin in the surrounding area does not contract too tightly, which may cause pain or restriction of movement. When a wound is healed, it must shrink back into its proper place and stay there until it’s time for complete closure.

Patients Role in Wound Care

Patients are the main role when it comes to maintaining the good health of their wounds. As a patient, it is up to them to make sure that they stick with the treatment and follow any orders given by doctors, nurses, or other medical care providers.

They are also the most knowledgeable about their body and how it functions, so they have to disclose any relevant information regarding their wound. This includes things such as what happened to cause the wound, medications taken that could affect healing, and current symptoms displayed by the wound itself.

When patients first get home after being involved in an accident or sustaining a wound, the first thing to do is clean their hands and surrounding areas with antibacterial soap.

Next, they should wash the wound itself using clean, warm water and antiseptic solution.

When washing off wounds, it is important to use cotton swabs until the area is dried off completely because moisture can cause scabbing, leading to infections or serious complications.

It’s a good idea for patients to keep scars clean, which they can do by using antibacterial soap and warm water every day.

Once the wound has closed up enough that it is no longer necessary to change dressings, then patients should follow these steps:

  1. Cleanse and dry the area.
  2. Put petroleum jelly on it after washing up.
  3. Cotton or gauze can be used to hold the dressing in place and keep the skin clean and dry.
  4. A swab should be used when applying topical medications to a specific area.
  5. If a patient has an infection, they are to call their doctor or nurse immediately.
  6. Patients need to maintain an open line of communication with their doctor and nurses to assess any changes that occur in the wound and make sure that the patient is healing properly.
  7. They should also be willing to return for further examinations if necessary.

Summary

Though there are many different types of wounds, patients can still take the same steps in caring for them all.

They must follow their treatment plan closely, maintain good health of the wound, and maintain an open line of communication with whoever is attending to them so both can work together in getting the recovery process done as quickly as possible.

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