These tips-seme eld, some new-will help youmeet the chalienge of assessing and caring foryour patient's wound.

12 COIVUVIANDMENTS

earncEUs

ANA/AACN-APPROVED

WOUND CARE HAS CHANGEDdramatically in the past 10 years —in fact, it continually evolves. Butyou can count on one thing notchanging: the critical need for youto assess how well the wound ishealing and to choose the best treat-ment option for continuing that pro-cess.

The 12 commandments of woundcare presented here will help you dojust that. They incorporate time-tested care tips and some of thenewest trends.

Assess the woundthoroughlyYou'll go through sev-eral steps.

• \kasure the wound. Choose themost appropriate way to measureyour patients particular wound andstick with it throughout the healingprocess. For example, you'd want toknow the exact depth of a deepwound or the perimeter of a super-ficial, contracting wound.

To improve your assessment.,make sure the patient is in the sameposition each time you measure thewound. And if possible., you shouldalways be the one to do it.

Measure the wound in centime-ters. Start with the length (head totoe) and width (side to side) —basicmeasurements that you should havefor all wounds.

If the patient has a deep wound,determine the depth by inserting asterile cotton swab at the deepestpoint of the wound, then holding the

BY DIANE KRASNER, RN, CETN, MSNursing Consultont, Enterostomal TherapyBaltimore, Maryland

swab against a centimeter measur-ing guide. This works only for awound that's been debrided—youcan't accurately measure depth in awound covered by necrotic tissue,such as eschar (black, leathery,dried collagen) or slough (soft, yel-low, gummy debris).

One more thing about depth: De-vices designed specifically to mea-sure it are generally used in re-search only because they're too ex-pensive for bedside care. If you useda new one each time you measureda wound, your hospital would spendhundreds of thousands of dollars ayear on these deviees alone. Evenless-expensive devices aren't practi-cal because they're difficult to use;some aren't sterile either.

Monitoring the perimeter of ashallow wound will help you assesshow well it's healing. Plastic mea-suring guides with concentric circlesare available. Some dressings evenincorporate a sizing grid.

But you ean also make your ownguide with a plastic bag. Place thebag over the wound and trace theouter margins with an indeliblemarker. Cut off and discard the sideof the bag that touched the wound-it's contaminated. Then date andidentify the remaining piece of plas-tic and put it in the patient's record.

You can measure undermining ortunneling (breakdown of tissue be-neath intact skin, resulting in pock-ets or air space) with a sterile cottonswab. Slide the swab into the open-ing in the skin surface and along themuscle or fascial plane until youmeet resistance. Withdraw the swab,measure the extent of the under-mining or tunneling in centimeters.

34 NURSING92, DECEMBER

then relate the location to a clock orcompass face. For example, youmight find 3 cm of undermining at9 o'clock. Make sure you sketch thewound in your notes so other healthcare providers will understand yourpoint of reference. And you can useterms such as "proximal," "medial,"and "lateral" to help with orienta-tion.o Identify the wound type. Ask your-self these questions: Is the woundacute (an abrasion or skin tear) orchronic (a pressure ulcer, diabeticulcer, or venous ulcer)? Can you de-termine its etiology? For example,was it eaused by pressure on the sa-erum from the patient lying on hisback for too long? Have diabeticneuropathy and poorly fitting shoescaused a diabetic foot ulcer? Has ve-nous stasis ulceration occurred be-cause external compression stock-itigs weren't used as a preventivemeasure?

Also, is the wound complicated bymore than one problem? For ex-ample, you could be dealing with awound that has a draining fistula, apressure ulcer with a secondary ma-lignancy, or a vascular problemthat's compromising tissue perfu-sion in the area. Identify and prior-itize interventions to address eachproblem.

Suppose the patient has a leg ul-cer caused by vascular insufficiency.He may need bypass graft surgery toimprove blood flow before that ulcerwill heal. To provide holistic eare,you may also have to administercompression therapy, give medica-tion to improve vascular tone, andapply topical wound treatments,o Determine the nursing diagnosis.

JOHN W. KARAPELOL'

For example "impaired skin integ-rity" is commonly used for partial-thickness wounds (superficial woundsthrough the epidermis but notthrough the dermis) and Stage I andII pressure ulcers. For full-thick nesswounds (deep tissue destruction ex-tending into subcutaneous tissue,musele, or bone) and Stage III andIV pressure ulcers, you might use"impaired tissue integrity.'*

"Altered oral mucous mem-branes" might be appropriate forpressure ulcers in the mouth fromendotraeheal tubes, poorly fittingdentures, or other mucosal wounds.(Remember, pressure ulcers aren'trestricted to the classic areas; youmay also see them on the back ofthe head, under the elbows, underairway tubes, and so on.) Patients athigh risk for skin breakdown can begiven the diagnosis "potential im-paired skin integrity"

Also, complete a risk-assessmenttool to predict the likelihood ofmore tissue trauma. You might usethe Norton or the Braden scale forassessing pressure ulcer risk. Thesescales evaluate such things as phys-ical and mental condition, activity,mobility, and nutrition on a numericscale. Other risk-assessment toolsare used for different types ofwounds. Check your policy and pro-cedure manuals to determine whichone is used at your hospital.* Assess the phase of the wound heal-ing process. Wounds may be in thereaction (inflammation), regenera-tion (production of granulation tis-sues), or remodeling (matrix for-mation) phase. You may find that achronic wound isn't healing becauseit's stalled in one phase. For exam-ple, a fungal infection could preventa wound from moving out of the re-action phase (sometimes called theinflammatory phase). As ordered,you"d treat the infection with topicalantifungal agents to help the woundprogress toward healing,o Stage a pressure ulcer. Some nursesinappropriately stage all types ofwounds. But only pressure ulcersshould be staged. For guidance,check the the National Pressure Ul-cer Advisory Panel's 1989 classifi-cation system (see Classifying Pres-sure Ulcers). This system has beenadopted nationwide, and it's part ofthe new pressure ulcer guidelinespublished by the US. Departmentof Health and Human Services'

PREVENTINGPRE5SURE ULCERSThe following points are excerptedfrom the Agency for Health CarePolicy and Research's recent guide-lines on predicting and preventingpressure ulcers.

Risk assessment• Consider all patients who arebedridden or chair-bound or whohave difficulty repositioning them-selves to be at risk for pressure ul-cers.• Select and use a risk-assessmentmethod (such as the Norton orBraden scale), then systematicallyevaluate each patient's risk factors.• Assess all at-risk patients whenthey're admitted to your institutionand at regular intervals.• Identify risk factors (such as de-creased mental status, moisture,incontinence, and nutritional defi-cits) and restrictions on reposition-ing (such as a flail chest or unsta-ble vertebral column) and takespecific preventive steps. Modifytfie patient's care plan accarding tothese risk factors.

Skin care and early treatment• Inspect tfie skin at least daily anddocument assessment results.• Individualize the patient's bathingschedule. Use a mild cleaningagent; avoid hot water and exces-sive friction.• Assess and treat incantinence. Ifit can't be controlled, clean the skinwhen it becomes soiled, use a top-ical moisture barrier, and selectunderpads or briefs that are absor-bent and dry quickly.• Use moisturizers for dry skin.Minimize environmental factorstfiat can lead to dry skin (low hu-midity and cold air, for example).• Don't massage skin over bonyprominences.• Use proper positioning, transfer-ring, and turning techniques tominimize skin injury from frictionand shear forces.• Use dry lubricants (cornstarch,for example) or protective cover-ings to reduce friction injury.• Identify and correct factors com-promising protein or calorie intake

and consider nutritional supple-ments or support.• Institute a rehabilitation programto maintain or improve the pa-tient's mobility and activity.• Monitor and document your in-terventions and their outcomes.

Positioning and support• Reposition bedridden patients atleast every 2 hours; chair-boundpatients, every hour. Prepare awritten repositioning schedule.• If a chair-bound patient can shifthis weight, teach him to do so ev-ery 1 5 minutes.• Place patients who are at risk forpressure ulcers on a pressure-reducing mattress or chair cushion.Don't use doughnut-type cushiondevices.• Consider postural alignment, dis-tribution of weight, balance andstability, and pressure relief whenpositioning a patient in a chair orwheelcfiair.• Use lifting devices (such as a tra-peze or bed linens) to move thepatient; don't drag him duringtransfers or position changes.• Use pillows or foam wedges tokeep bony prominences (such asknees and ankles) from direct con-tact with each other,• Use devices that totally relievepressure on the heels. For exam-ple, place pillows under the calf toraise heels aff the bed.• Avoid positioning the patient di-rectly on the trochanter of the fe-mur when he's in the side-lyingposition. Use tbe 30-degree lateralinclined position instead.• Elevate the head of the bed aslittle as possible (maximum: 30 de-grees) and for as short a time aspossible.

Prepared by (he Nokmol Pressure Ulcor Advisor/Panel (rom Pressure Ufcers in Adults: Predictionand Prevention, a ciinical practice guiddino pub-lished by the Agency fof Hoaltti Core Policy arxJResearch (AHCPR], Pubk Health Service, U.S.Deportrnent of Health and Human Services, May1992

For a copy of the clinicd practice guideline, •quick reference guide for clinicians, arxJ a pa.lient's guide, coH ths AHCPR Clearinghouse-1 -800-358-9295. Or write to. AHCPR Publita-lions Oearinghouse, P.O. Bon 8547, Silver Spring,MD 20907

3 6 NURStNG92, DECEMBER

Agency for Health Care Policy andResearch.

Other wounds may be describedas partial-thickness, full-thickness,acute, or chronic, or by etiology {ar-terial ulcer, for example). Use first-,second-, or third-degree to describeburns.• Other aspects to assess. Note thelocation of the wound, the color ofthe wound bed, the condition of thewound margins, and the integrity ofthe surrounding skin. Look forsigns and symptoms of infection,such as redness, warmth, swelling,and pain. Do you sec exudate? If so.what color is it? And does it have anodor?

O Outline a care planEach patient needs awound care plan that'stailored to his needs.

Standardized or standing woundcare protocols are fine, as long asthey can be individualized. Com-ponents of a comprehensive woundcare protocol might include a risk-assessment tool, a documentationflow sheet, standing treatment or-ders, and a surveillance plan (ameans for identifying how many pa-

CLASSIFYINGPRESSURE ULCERSStage INonbbnchable erythema of intactskin; the heralding lesion of skinulceration

Stage IIPartial-thick ness skin loss involvingepidermis or dermis. This ulcer issuperficial ond appears as anabrasion, blister, or shallow croter.

Stage IIIFull-thickness skin loss Involvingdamage or necrosis of subcuta-neous tissue that may extenddown to, but not through, underly-ing fascia. The ulcer appeors as adeep crater with or without under-mining of adjacent tissue.

Stage IVFull-thick ness skin loss with exten-sive destruction, tissue necrosis, ordomage to muscle, bone, or sup-porting structures (for example,tendon, joint capsules, and so on]

Adopted from tho Nolional Prassure Ulcer Advi-iory Ponel Consensus Development ConferenceSlotoment. 1989.

Measure the depth of the wound with osterile cotton swab.

Use on acetate woutid guide wrth concen-tric circles printed on it to measure thewound's perimeter.

Use a sterile cotton swab to measure tun-neling or undermining.

Qeon the wound with an angiocoth, sy-ringe, and normal saline solution.

Protect the wound margins with a dress-ing—here, a hydracolloid.

A dressing that retains moisture, such asthe transparent dressing over this wound,promotes autolysis of eschor.

Vfe opted to conservatively manage these blackened, intoct, Stage IV pressure ulcers(see commondment 11).

COMPARING WOUND DRESSINGS

Category Products Advantages Disadvantages

Cotton mesh gauze • Moderately absorbent Bulky

Nonadherent dressing • Nonimpregnated: ETE SterileProtective Dressing, EXU-DRY,Metalline, Release, Telfa• Impregnated: Adaptic, ScorletRed, \bseline Gauze, Xeroflo,Xeroform

• Occlusive• Nontraumatic

• Minimally absorbent• Some impregnated dress-ings contain antimicrobialagents that horm fibroblasts

Transparent film • ACU-Derm, Biodusive,BllsterFilm, Ensure-It, Hi/moist,Omiderm, OpraFlex, OpSite,Polyderm Picture Frame Film,Fblyskin II, Tegaderm, Tega-derm Fbuch, Transite ExudateTransfer Film, UniFlex, \ t i r i /Moist, Visi Derm 11

• Moisture retentive• Semlpermeable• \fery comfortable for patient• Not bulky• Allows for easy wound in-spection• Vfeter resistant

• Minimally absorbent• Channeling (wrinkling)occurs

Mydrocolloid • Comfeel, DuoDERM, Hydra-pad, Intact, intraSite, Johnson &Johnson Ucer Dressing, Re-store, Sv/een-A-Peel, Tegasorb,ULTEC

• Moisture retentive• Occlusive or semipermeable• \fery comfortable for patient• Not bulky• Excellent bacterial barriers,high tack• Vfater resistant• Moderately absorbent

• Melt out occurs, resulting inresidue in the wound bed andparticles on the wound mar-gins

Hydrogd • Biolex \ ^ u n d Gel, CarringtonDermal V f̂eund Gel, GearSite,Elasto-Gel, Geliperm Wet/Granulate, Hydron VtourxJDressing, IntraSite Gel, Nu-Gel,Second Skin, Spand-Gel, Vigilon

• Moisture retentive• Moderately absorbent• Cooling, soothing effects• Can be used an infectedwounds• VAiter resistant (if used withsecondary transparent film)• Allows for easy wound in-spection

Exudote absorber • Algosteril, Allevyn CavityVfciund Dressings, Bard Absorp-tion Dressing, Debrisan, Envi-san, Hydragon, Kaltostat,Mesalt, Sorbsan

Moisture retentiveHighly absorbent

Foam • Allevyn, EPIGARD, Epi-Lock,LYOfoam, Mitroflex

Moisture retentive\fery comfortable for patientModerately absorbentInsulating

Note: The products included here are representativs of wtwt's avoilobb,- Ihe lists under each category oren't meant to be inclusive.

From "Seleeling Wound Drwjinfls by Catogory." NAMD Journal.'^ 1991 Notional Association of Retail Druggists. Alexandria, Wi., May 1991. Adapted with permission of the pubNshef

NURSING92, DECEMBER

Nursing considerations

• Can be used dry to cover surgi-cal wounds, wet-to-dry to nonse-lectively debride some wounds,and moist to pack underminingand tunneling

• Combine with normal saline so-lution for granulation or antibioticsolutions for infection• Use transparent films or occlusivetope to retain moisture, p.m.• Cover with nonwoven gauzes toincrease absorption

• Nonodhesive• Doesn't require secondary dress-ing• Useful for skin tears and otherfriable wounds, wounds near bodyhair, donor sites, and skin grafts

• Adhesive• Doesn't require secondary dress-ing• Useful for autolytic debridement,as well as superficial wounds, do-nor sites, obrasions, and burns

• Adhesive• Doesn't require secondary dress-ing• Useful for autolytic debridement,as well as for covering a variety ofacute and chronic wounds• Available in powder, wafer, andpaste form

• Adhesive or nonadhesive• May or may not require second-ary dressing• Useful for autolytic debridement,as well OS for covering a variety ofacute and chronic wounds• Available in sheet or gel forms• Sheets don't leave a residue; geteasily rinsed off

• Nonadhesive• Requires secondary dressing• Useful for autolytic debridementand for heavily exudating wounds• Available as starches, pastes,beads, hypertonic saline gauzes,and calcium alginote dressings

• Nonadherent• May or may not require second-ary dressing• Useful for friable wounds orwourwds near body hair

tients in the institution have woundsor pressure ulcers and how many ofthese developed after admission).

You don't have to write your pro-tocols from scratch: Printed careplans and guidelines can serve asmodels for developing specific stan-dards for your institution. For ex-ample, the International Associationfor Enterostomal Therapy sells itsstandards of care for pressure andleg ulcers. Or you could get a copyof the new pressure ulcer guidelinesfrom the Agency for Health CarePolicy and Research.

O Modify the plan,p.r.n.A plan that looks greaton paper may not

stand up to the reality test. In otherwords, be prepared to modify andrevise your plan as necessary.

Be prepared to reconsider yourchoice of dressing as the wound'sstatus changes. Wet-to-dry dress-ings, for example, are no longer usedthroughout the healing process. Butyou could still start with one to non-selectively debride a wound that'sfull of slough. Once the wound isclean, though, you'd switch to adressing that would allow granula-tion, such as a hydrocolloid or hy-drogel. At that point, a wet-to-drydressing could debride healing tissueand put you back at square one.Later, you'd move to a dressing thatwould promote reepithelialization,such as a composite or transparentfilm dressing. The bottom line isthis; Treatment must evolve as thewound heals.

O Keep the wound bedmoistA landmark studypublished 30 years ago

demonstrated that wounds healfaster with less scarring in a moistenvironment than in a dry one. Amoist environment promotes fastergranulation and reepithelializationand reduces pain. So stay away fromantacids, heat lamps, and other top-ical treatments that dry out thewound bed.

Moisture-retentive dressings areeasy to use and cost-effective be-cause they're changed less fre-quently than other dressings—somedressings can remain in place for upto 5 days. Many moisture-retentivedressings can be applied using a no-

touch technique that saves supplies,nursing time, and money. Traditionalgauze dressings, by comparison, arechanged two or three times a dayand must be applied using steriletechnique. So they tend to be veryexpensive.

O Keep the wound bedclean and debridedThe wound bed mustbe carefully cleaned

before you apply the new dressing.This is critical: You can't just pull offthe old dressing and apply a newone.

To clean the wound, use a solutionthat's free of cytotoxic agents ordangerous chemicals; otherwise,macrophages, fibroblasts, and deli-cate granulation tissue could beharmed. For most wounds, normalsaline solution is the agent of choice.Besides being gentle to healing tis-sue, it's also cost-effective —specialcleaners cost three to four timesmore than normal saline solution.

But some wounds—such as trau-matic wounds filled with gravel androad debris—must be cleaned withspecial nonionic surfactant cleaners(Shur-Clens and Saf-Ciens. for ex-ample). These break up the debriswithout damaging tissue; they're es-pecially effective for removing driedblood, exudate, and foreign matter.This helps reduce infection rates incontaminated wounds.

You may also have to irrigate awound filled with a lot of debris orexudate. Use an 18- or 19-gauge an-giocath and a 30- or 35-ml syringe.This combination produces 8 to 11pounds per square inch of pressureat the wound surface—a safe amount.Anything higher could damage thewound or drive bacteria into the tis-sue.

If the wound has copious exudate,try using an exudate-absorbingproduct to keep the wound clean.For example, you might select fromamong the calcium alginates. co-polymer starches, foams, and hyper-tonic saline dressings.

An incontinent patient withwounds in the sacral/coccyx area,buttocks, or thighs may need a col-lection device. A fecal collector, uri-nary pouch, or external catheterwill help protect the area from con-tamination, maceration, and furthertissue trauma. In extreme cases, thepatient may need a coiostomy, ile-

NURS1NG92, DECEMBER 9 t

ostomy, or urostomy to permanentlydivert stool or urine and allow thewound to heal —and stay healed.

If the wound contains eschar orslough, it must be debrided. You canuse wet-to-dry gauze if the wound isfilled with necrotic debris. But dis-continue this method as soon as thewound is clean. Whirlpool is an-other form of nonselective debride-ment that may be useful for somewounds, such as diabetic or venousulcers.

Enzymatic debridement, a chem-ical process, is a selective debride-ment method—it doesn't damagehealthy tissue. Carefully read thepackage inserts of the productsyou re using. Different types of en-zymes behave differently and re-quire specific secondary dressingsand changing schedules. Watch foradverse reactions such as inflam-mation or pain.

Enzymatic debridement is contra-indicated in patients with clottingdisorders. As with any type of de-bridement, it should be used cau-tiously in patients with infection,cellulitis. cavity wounds, woundswith exposed nerves, or neoplasms.

A doctor can perform surgicaldebridement, another selectivemethod, at the bedside or in the op-erating room, depending on the ex-tent of the wound. Surgical debride-ment is fast and can be extremelyeffective when performed skillfully.It's contraindicated for patients withclotting disorders.

In some cases, nurses who havespecial preparation (usually nursepractitioners, clinical nurse special-ists, and enterostomal therapynurses) can perform this procedureon clearly identified necrotic tissue.Check your nurse practice act andyour hospital's policy and proceduremanuals to find out what's allowedin your state and at your institution.

Autolytic debridement is the new-est method of selective debridement.It's versatile and easy to perform-all you do is cover the wound withan occlusive or semiocclusive dress-ing to provide a moist environment.The body's own defense mecha-nisms clean the wound of necroticdebris.

This process isn't as fast as sur-gical debridement, but it's more se-lective and usually painless for thepatient. Transparent film dressings,hydrocolloids and hydrogels are

good choices to promote autolysis.But use caution with immunosup-pressed patients or patients with in-fected wounds.

O Protect healthy tissueGood skin surround-ing a wound is vulner-able to maceration,

erosion, and insults from wound ex-udate, repeated dressing changes, orother trauma. If the skin is still in-tact, you can protect it with skinsealants or moisture-barrier oint-ments. But if the skin is broken,you'll need to apply a dressing thatretains moisture (such as a trans-parent film dressing or a hydrocol-loid) to protect the wound margins.

Use a pressure-relieving device—for example, pillows, chair cushions,mattress overlays, or specialty beds— to protect skin and tissue fromischemia. But don't use doughnutcushion devices because they createlarger areas of ischemia.

O Select dressingsthoughtfullyThe proper dressingwill help the wound

heal. That's why you need to care-fully consider the dressings avail-able and choose the one that willbest suit your patient's needs. Checkthe specific advantages and disad-vantages of them in ComparingWound Dressings. The broader therange of products in your arsenal,the better your chances of selectingthe right dressing for a wound.

Sometimes you may need to com-bine products from different cate-gories to produce the best result-in fact, combining dressings Is thewave of the future in wound care.For example, you might use a hy-drogel to keep the wound bed moist,cover it with a foam to adsorb ex-cess exudate, and cover that with atransparent film to retain moistureand provide a secondary dressing.

You can't combine these dressingshaphazardly, though—you need toknow which products complementeach other so you don't harm the pa-tient. Combining an occlusive dress-ing with an enzymatic debridingagent, for example, could cause se-vere cellulitis and seriously damagethe wound. Make sure you read theguidelines on the package insertsfor information on safely combiningproducts.

O Eliminate dead spaceExudate or woundfluid can accumulatein undermined or tun-

neled areas or in sinus tracts. Theseareas are known as "dead space."Dead space becomes a breedingground for bacteria and other or-ganisms. To prevent problems, elim-inate the dead space by lightly pack-ing it with gauze strips or rolls or byfilling the space with an exudate-absorbing product, such as calciumalginates, copolymer starches, ab-sorption dressings, foams, hydro-colloid paste, or hypertonic salinegauze..

oEvaluate andreevaluate the woundSome wounds are sim-ply baffling. If you

aren't sure what you're seeing, con-sult your enterostomal therapynurse, clinical nurse specialist,wound care specialist, a dermatolo-gist, or a plastic surgeon immedi-ately.

Similarly, you'd consult a special-ist if the wound hadn't responded to1 or 2 weeks of treatment. Cancercan develop in chronic wounds, de-laying healing. Serial biopsies of sus-picious lesions in the wound willrule this out. Other common causesof delayed wound healing includesystemic factors (such as ischemiaor poor nutrition and hydration sta-tus) and local factors (such as sub-clinical infections and unrelievedpressure).

Impaired circulation will delayhealing too. Without blood flow tothe area, the wound won't get theblood, oxygen, and nutrients neededfor regeneration and repair. Toxicsubstances build up in the area, fur-ther delaying healing. And somebacteria thrive in an ischemic envi-ronment. If this is the cause of de-layed healing, consult with a doctorto determine how circulation can beimproved.

© Control costsTreating wounds iscostly. So focusing onprevention and early

intervention rather than treatmentitself is a cost-saving philosophy—the old adage "an ounce of preven-tion is worth a pound of cure" is sotrue in wound care. You can save alot of money for your itistitution and

40 NURSING92, DECEMBER

your patient by using wound careproducts judiciously.

For example, suppose your patientis at high risk for a pressure ulcerand you apply a pressure-relievingdevice costing $50. That's moneywell spent if it prevents a pressureulcer, which couJd cost as much as$30,000 to treat —not to mention thepain and suffering the patient wouldhave lo endure.

A homebound patient can cutcosts too. Why should he spend $6for a bottle of normal saline solutionto fiush a wound when he could sim-ply add 2 teaspoons of salt to a literof boiled water that's been cooled?The result is the same.

Many studies have shown that thecostliest component of dressingchanges is the nurse's time. Usingdressings that need changing lessfrequently (for example, hydrocol-loids, hydrogels, calcium alginates,exudate absorbers, and foams) savesthousands of nursing hours.

Also, using a no-touch techniquefor selected wounds instead of strictsterile technique can save a singiefacility hundreds of thousands ofdollars a year on sterile gloves,drapes, and barriers.

O Know your limits andthe limits oftreatmentYour state's nurse

practice act sets the limits of yourwound care. For example, RNs in allstates can perform routine woundcare and dressing changes. As Imentioned, only some states allowyou to perform surgical debride-ment. Make sure you're familiar

with the scope of practice in yourarea.

Also, recognize which woundsshould be left alone. I once cared fora bedridden woman with blackened,intact. Stage IV pressure ulcers onher heels. Because she had poor cir-culation in her legs, we didn't de-bride these pressure ulcers. Doingso would have created deep, openwounds that wouldn't have healed—but could have become routes forsystemic infection. So we elevatedher legs with pillows to relieve pres-sure on the heels and monitored theeschar to make sure it didn't worsen.Similarly conservative treatmentmight be appropriate for a termi-nally ill patient —subjecting him topotentially painful treatment maybe counterproductive In his lastweeks of life.

Certain wounds are beyond thescope of topical treatment and willrequire surgical intervention. Referseverely undermined or tunnelingwounds, wounds over difficult areas(joints, elbows, or the greater tro-chanter), wounds involving bone,and deep wounds in immunocom-promised patients to a surgeon orplastic surgeon for evaluation. Thepatient may need a myocutaneousflap repair to cover a wound thatisn't healing.

© IVeat the wholepatient, not just thewoundA wound disrupts the

patient's entire life, so provide hol-istic care. Nutritional support maybe as important as local wound care.Without enough proteins, vitamins.

minerals, and calories, the patientcan't form the collagen and granu-lation tissue needed to regenerateand repair the wound. Monitorserum albumin levels and request anutritional consultation if the resultsare borderline or low.

Also watch the patient's hydra-tion. If it's inadequate or if he'sshowing signs of dehydration (de-creased skin turgor and sunken eye-balls, for example), carefully moni-tor his intake and output and givefluid replacement as needed.

And don't forget the medical ornursing problem that brought thepatient to the hospital in the firstplaee—patients are rarely admittedsolely because they have a woundthat hasn't healed. Draw on theskills of a multidisciplinary team ofhealth care professionals —includingnurses, doctors, physical therapistsnutritionists, pharmacists, and socialworkers —to deliver the comprehen-sive care your patient needs. B

SELECTED REFERENCESColburn, L.: "Preveniing Pressure Utcers: Howto Recognize and Care for Puticnis at Risk."Nursin^,90. 20(12):6()-6.'i. December tWO.

Krasner, D.: "Resotvingttic Dressing Ditemma;Selecting Wound Dressings by Category,"OslomylWaund Mana^menl. 35:62. 64-70, July/August 1991.

Krasner. D. ^ d ) : Chronic Wound Care: A Clin-ical Source Book for Healthcare Professionals.King of Prussia, Pa.. Health Management Pub-lications. 1990.

Maklebust, J., and Sieggreen. tW.: Pressure Ul-cers: Guidelines for Prevention and NursingManagement. West Dundee, lit.. S-N Pubtica-lions. Inc.. 1991.

National Pressure Utcer Advisory Panel: "Pres-sure Utcers—Prevalence. Cost and Risk As-sessment: Consensus Development ConferenceStatement." Decuhitiis. 2(2):24-:a, May 1989.

Panet for the Prediction and Prevention of Pres-sure Utcers in Adutts: Pressure Ukerx in Adults:Prediction and Prevention. Rockvitte. Md.,Agency for Health Care Policy and Research,May 1992.

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is accredited as a provider of con-tinuing education in nursing bythe American Nurses Credential-ing Center's Commission on Ac-creditation.* You'll also receivean answer booklet containingthe rationale for each correctanswer. If you fail the test, ananswer booklet will not be sentso that you'll have the option oftaking the test again (at no ad-ditional cost).

•Provider numbers: Alobama, ABNP0210;California, 5264; Florida, 2710600; ondlowo, 136 (Caiegory 1). Approved by theAACN for 3 contact hours.

NURSING92, DECEMBER 4 1

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THE 12 COMMANDMENTS OF WOUND CARECEU OBJECTIVES After reoding the preceding orticle and toking this test, you shoukJ be able to: 1 . ktentify data to assess a wound.2. Identify a wound care pbn. 3. Identify solutions artd dressings to be used specific to wound core pnablems. 4 . ktentify cbssificationstages of pressure ukers arxJ nursing octions to prevent pressure ulcers from developing.

Measure the depth of a wound by1. inserting a gloved finger into the wound un-

til you reach the bottom.2. inspecting the wound and comparing it with

a common object.3. using a measuring guide with concentric cir-

cles.4. inserting a sterile cotton swab, then holding

it against a centimeter measuring guide.

You can make your own guide for mea-suring the perimeter of a shallow wound

by1. piecing a plastic bag over the wound and

tracing the outer morgins with an indeliblemarker.

2. drawing concentric circles 1 cm apart on apiece of rigid plastic or old X-ray film.

3. using the sterile side af o dressing wropperand an indelible marker.

4. comparing it with voriaus common objectsas its size chor>ges.

When measuring wound undermining ortunneling, you'd

1. use a plastic meosuring guide with concen-tric circles.

2. relate the location to a clock face.3. use 0 centimeter measuring guide.4. use • gloved finger to explore its depth.

If the patient has a fuil-thickness wound,your nursing diagnosis wouid be1. potential impaired skin integrity.2. impoired skin integrity.3. impaired tissue integrity.4. impaired mucous membranes.

Wet-to-dry dressings are used to1. nonselectively debride a wound.2. promote gronulation tissue growth.3. break up debris without damaging tissue.4. promote macrophage formation.

6. The agent of choice for cleaning mostwounds is1. povidone-iodine.2. hydrogen peroxide.3. sterile distilled woter.4. normal soline solution.

7. Calcium alginates and hypertonic salinedressings are used to

1. debride wounds.2. absorb copious exudate.3. treat local wound infections.4. stimulate granubtion.

B. Debride wounds that are1. infected.2. producing copious exudate.3. healing slowly.4. full of eschar or slough.

9. Which of the following is true aboutwound care treatments?1. Hydrogels promote autolysis.2. An occlusive dressing can be combined with

on enzymatic debriding agent.3. Packing a wound with gauze strips helps the

wound retain moisture.4. A hydrogel con't be combined with a foam

dressing.

10. To protect skin and tissue from ischemia,you'd use a1. doughnut cushion device.2. skin sealant or moisture-barrier ointment.3. transparent film dressing.4. pressure-relieving device.

11. If a wound hasn't responded to treat-ment in G week or two, you'd1. revise your entire plan.2. culture the wound.3. consult 0 specialist.

4. try a different dressing.

12. Which dressing would you use to non-selectively debrkle some wounds?1. Tegaderm 3. cotton mesh gauze2. Svireen-A-Peel 4. Adaptic

13. One way to control the cost of woundtreatment is to1. use the least expensive product avaibbte.2. use strict sterile technique to prevent sec-

ondory infection.3. make your own normal saline solution in the

unit kitchen.

4. use dressings that require less-frequentchonging.

14. A pressure ulcer that appears as a deepcrater without undermining of adjacenttissue would be classified as

1. Stage I. 3. Stage III.2. Stage II. 4, Stage IV.

15. Skin care and early treatment to preventpressure ulcers should include1. massaging skin over bony prominences at

each repositioning.2. daily skin inspection v/ith documented as-

sessment,3. applying a moisturizer to reduce friction in-

juries.4. using indwelling catheters for urinary incon-

tinence to prevent skin breokdown.

16. Positioning and support measures toprevent pressure ulcers include1. repositioning chair-bound pottents every

hour.2. using pressure-reducing mattresses or chair

cushions (or all patients.

3. using foam or synthetic sheepskin heelboots on patients who may be at risk forpressure ulcers.

4. turning patients side to side every 2 hoursand using the full loterol position.

'1

Name

Carefully cut along dotted line.

ANSWER FORM: WOUND CAREInclixle on Ihis form all your answers from the above tesi. Use o No. 2 perxiil, noi • pen. and press hord.

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(Please prini clearly)

Address.

City

Social

Siate(s) of Licensure andNursing License No.fs]

State. ZIP.

Before the expirotion dote of November 30, 1993, cut out tfiis form and mail it to; The Nursng Institute, 2710 Yorktowne Blvd., Brick, NJ 08723. Be sure toanswer all the questions and enclose your check for $ 1 2 . 9 5 , payable to The Nursing Institute.

WM