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Wound Care
NURS1000: Discovering what nurses actually do :
A snapshot of nursing practice
CUHK Summer Institute 202 5
Dr Cheryl Yeung
Professional Consultant
The Nethersole School of Nursing
Faculty of Medicine
The Chinees University of Hong Kong 1Learning Outcomes
Categorize types of wounds
Describe staging of pressure ulcers
Discuss the development & prevention of pressure ulcers
Describe the principles in wound dressing Anatomy of
# the Skin
> 3
## What are wounds?
Refers to a break or discontinuity of skin or other body tissues
Which of the followings are wounds?
> ABC
> DEF
> 4
## Types of wound
> 5
Abrasions
Top layer of the skin is removed
Usually embedded with dirt
Lacerations
Cuts of the skin
May lead to profuse bleeding
Possibility of tendon or nerve injuries Incisions
Smooth edges and resemble a paper cut
Blood vessels are cut straight across
Punctures
Penetration by sharps, e.g. nail or knife
Usually deep, narrow wounds
May result serious internal injury
> 6
Avulsions
Where a flap of skin is forcefully torn
from its attachment
Amputations
Partial or full detachment of a limb or
other appendage of the body
> 7
Gunshot wound
Wound size depends on types of gun & size of
missile
Entry site may be burnt
Blast injury
Explosive accident
May cause serious internal injury and multiple
tissue necrosis
> 8
Surgical wound
- Is the cut made to the skin by surgeon during an operation
> 9
> Skin graft Staples Sutured wound
Gangrene wound
Death of body tissue due to a lack of
blood flow or a serious bacterial
infection
Could be due to diabetes, vascular
problems or infection
> 10
Burn wound
caused by thermal, electrical, chemical,
or radiation energy
Classified into superficial, partial
thickness, full thickness burn
> 11
Fungating wound
Chronic wounds related to malignancy
When cancer that is growing under the
skin breaks through the skin to create a
wound.
> 12
## Categories of wound healing time
Acute wound
A sudden injury to skin that normally heals at predictable
and expected rate
e.g. surgical, burns, laceration, abrasion
Chronic wound
May progress from acute wound that fails to heal within
expected time
The repair process fails to restore anatomic and functional
integrity after three months
e.g. pressure ulcer, eschar
> 13
> Eschar = dead necrotic tissue
14 What are pressure ulcers?
Other names: Pressure sores, or bed sores
Definition: a localized injury to skin and/or underlying tissue caused by
prolonged pressure usually over bony prominence
Aggravating factors: Moisture, shearing force
Certain populations at higher risk of developing pressure ulcers
e.g. bedbound patients
One of the key indicators of quality care Common Body Pressure Areas
> (Berman & Snyder, 2012)
## Assessment of Pressure Ulcers
Pressure ulcers are graded and staged to classify degree of tissue
damage
Staging of pressure ulcers was reviewed and updated by the National
Pressure Ulcer Advisory Panel in 2007
> (NPUAP, 2014)
> Stage 1 Stage 2 Stage 3 Stage 4
## Staging of Pressure Ulcers
Pressure ulcer staging:
Stage 1
Stage 2
Stage 3
Stage 4
Unstageable and suspected deep tissue injury Stage 1:
Non -blanchable erythema
Intact skin with non -blanchable redness
of a localized area usually over a bony
prominence
Epidermis remains intact
May be painful, firm, soft, warmer/cooler
compared to adjacent tissue
Difficult to detect in dark -skinned tones
- May not have visible blanching and
color may differ from surrounding area
> (NPUAP, 2014)
> 19
Stage 2:
Partial Thickness
Partial thickness loss of dermis
>
Shallow open ulcer with red
pink wound bed
>
Shiny dry ulcer without slough
or bruising
Presents clinically as abrasion,
blister, or shallow crater
> (NPUAP, 2014)
> 20
Stage 3:
Full Thickness Tissue Loss
Full thickness tissue loss
Subcutaneous fat may be visible
No exposed bone or muscle
Slough may be present, but does
not obscure depth of tissue loss
Presents as deep crater
May or may not include
undermining and tunneling
> (NPUAP, 2014)
> 21
Stage 4:
Full Thickness Tissue Loss
Full thickness tissue loss with
extensive destruction and tissue
necrosis
> o
Exposed bone or muscle is
visible or directly palpable
Slough or eschar may be present
Includes undermining &
tunneling
> (NPUAP, 2014)
> 22
## Undermining & Tunneling Unstageable (1)
Suspected deep tissue injury (depth unknown)
Area of discolored intact skin or blood -filled blister
due to damage of underlying soft tissue
Painful, firm, mushy, boggy, warmer/cooler compared
to adjacent tissue
> (NPUAP, 2014)
Actual depth of ulcer completely covered by
slough and/or eschar
True depth cannot be determined
Unstageable: Full thickness skin or tissue loss (depth unknown)
> (NPUAP, 2014)
## Unstageable (2) Exercise
How do you categorize the
staging of this ulcer? Exercise
How do you categorize the
staging of this ulcer? Exercise
How do you categorize the
staging of this ulcer? Exercise
How do you categorize the
staging of this ulcer? Exercise
How do you categorize the
staging of this ulcer? Pressure Ulcer Prevention
> 1.
Routine systematic skin assessment
> 2.
Encourage mobility & repositioning
> 3.
Reduce friction & shear
> 4.
Use devices to prevent pressure ulcers
> 5.
Incontinence care
> 6.
Provide skin care and early treatment
> 7.
Optimize nutritional support Skills in wound care Purpose of Wound Dressing
Remove foreign debris or wound surface contaminants
Remove excess exudates
Remove crusts
Remove previous topical application
Protect granulation tissue
Promote wound healing
Remove, Protect & Promote! Essential points in wound dressing
Standard precautions
Patient & wound assessment
Aseptic dressing techniques
Appropriate wound cleansing approach
Accurate documentation
Ensure privacy Patient assessment
Medical/surgical history
Medication history
Allergies: cleansing solutions, adhesive tape, dressing materials, meds
General condition
Physical needs
Psychosocial needs
Past experience & knowledge Wound assessment (1)
Etiology
Duration
Anatomical location
Size
Shape Wound assessment (2)
Exudate/pus/odor
Wound bed
Surrounding skin
Wound edge
Tunneling
Undermining Wound dressing (1)
Purpose:
To clean a wound using aseptic dressing technique
To apply a dry & sterile dressing appropriately
To assess for signs & symptoms of wound complications (if any) Wound dressing (2)
Equipment
Dressing trolley Adhesive tape or bandage
70% alcohol wipes Sterile dressing materials
Sterile dressing pack Personal protective equipment (PPE)
Cleansing solution
(e.g. 0.9% sodium chloride irrigation ,
chlorhexidine 0.05%)
Incontinence pad
Latex and s terile gloves Paper or plastic bag to contain trash Gauze
Foams Tulle gras dressing
Opsite film Hydrocolloid
## Wound care products Hydrogel Silver dressing
Alginate Enzymatic dressing
Collagen dressing Silicone dressing Aseptic dressing technique
Sterile vs non -sterile
Sterile materials must be kept dry
Arrange sterile items within 2.5 cm of outer
edge of sterile field
Maintain forceps in downward direction
No reaching over/turn away from sterile
field/objects Wound dressing
Video watching:
OSCE Aseptic Non -Touch Technique Wound Dressing
https://youtu.be/UzK6eh72tI0?si=DU3rcYZ6t3AfPvbV
> 44
## Wound dressing (3)
> 1.
Assessment & planning
Environment (safe, clean, adequate lighting)
> 2.
Equipment
Prepare dressing trolley
Dry, intact package, not expired
> 3.
Body mechanics Wound dressing (4)
> 4.
Prepare sterile field
> 5.
Prepare & arrange sterile items on sterile field
> 6.
Techniques:
Swab gently & thoroughly
One stroke -one swab only
Cleansing directions: from top to bottom (or) center to
outside (or) clean to dirty
Swab wound bed, margin and surrounding skin Wound dressing (5)
7. Care of patient
Comfortable position
Patient education
8. Care of equipment
Proper disposal of used materials
General waste vs clinical waste
9. Documentation RED clinical waste bag
> Dressings with blood or
> body fluids
> Yellow clinical waste bag
> Human or animal tissue
## Documentation
Wound condition
Dressing/treatment provided
Clients response & tolerance to procedure
Health education provided
Signature, date & time
Report to doctor or nurse -in -charge, if needed Sample Nursing Documentation 49 Hospital Authority (2022).Innovative Community Nursing App Accessing
wound care progress at finger tip.
https://www3.ha.org.hk/ehaslink/issue118/en/feature -3.html
The Wound App can record and
present an exhaustive view of a
patients wound progress in a
paperless way
allows comparison of wound
conditions at different stages with
wound photos and progress.
Big data analysis of the collected
information also reflects treatment
effectiveness and usage of
dressings, thereby enabling better
resources planning and
continuous service improvement
> 50
# Advanced wound care
> 51
## Negative Pressure Wound Therapy
Video link:
https://youtu.be/4yPnWIrLKhg
Sources: Acelity
> 52
## Maggot debridement therapy
Video link:
https://youtu.be/6Xt6NWkgydM
Source: National Geographic
> 53
## Multidisciplinary care in wound care
Surgeons
Doctors from different specialties (Endocrine, pain team, infectious
disease, vascular, plastic, etc )
Wound nurse
Infection control nurse
Dietitian
Physiotherapists
Social worker
Family caregivers
> 54
Treating The Whole Patient
Not Just The Hole In The Patient
> (Dr. Carrie Sussman)
> 55
## Extra learning resources
Wound management home skills programme
https://www.youtube.com/playlist?list=PLe1WVrjVvNFfaIT4wKn8Pd8AlUzOueixt
> 56
## References
Berman, A., Snyder, S. J., & Frandsen, G. (2021). Kozier & Erbs
fundamentals of nursing: Concepts, process, and practice (11th
ed.). Pearson Education Limited.
Brown , P. A. (Eds.) (2013). Quick reference to wound care: Palliative, home,
and clinical practices (4th ed.). Jones & Bartlett Learning.
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2018). Clinical nursing
skills and techniques (9th ed.). Elsevier.