nursing case study examples wound care

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Case series: Shared wound care discussion guide

Shared care encompasses approaches and interventions that may enable patients to participate in care planning, decision making and care delivery. This approach values the patient as an active participant rather than a passive recipient of care, and is a key part of management for a range of other conditions (Wounds International, 2016). Patient involvement can not only improve wound care outcomes, but also reduce the economic burden and improve quality of life (Hibbard and Gilburt, 2014).

Shared wound care extends beyond the patient to engage with the patients’ informal carer(s) (member[s] of a person’s social network, e.g. family, friend or guardian) who helps the individual with activities of daily living, and may assist with the patient’s wound-related care. 

The shared wound care discussion guide (SWCDG) was developed as an aid for clinicians to use with the patient and informal carer(s) to discuss their awareness, willingness and ability to be involved in shared wound care (Moore et al, 2021). The SWCDG builds on international research and guidelines (e.g. Wounds International, 2016) plus survey results from clinicians (Moore and Coggins, 2021) and patients (Moore et al, 2021) that identified educational support is needed for clinicians to help patients and informal carers participate in shared wound care (Miller and Kapp, 2015; Kapp and Santamaria, 2017).

This case series describes how the SWCDG was evaluated in clinical practice by five wound care specialists in Australia, Canada, The Netherlands and the United Kingdom. The SWCDG was used during the initial patient and wound assessment to prompt conversation about shared wound care. The individual wound care dressing regimens were devised in collaboration between the clinician and the patient. The participants fears, concerns and thoughts on shared wound care were recorded. Each patient was monitored and reviewed for approximately 4 weeks or longer. Parameters of wound healing were recorded, such as wound size, wound bed condition and wound progression. 

Overall, clinicians reported that using the SWCDG helped to facilitate shared wound care. The patients and their carers (if applicable) reported feeling more independent and empowered to be involved in their own care. There were decreased clinic visits and regular communication between the patient and clinician. If the patient was in a residential or nursing home, an additional benefit was that the nursing staff were upskilled in their wound care knowledge and felt confident that the patients could take an active role in their own wound care. 

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Wound care: Five evidence-based practices

The best practices for the best outcomes.

• Managing co-morbidities is key to wound care management.
• Clinical evidence does not support sterile over clean technique in wound care.
• Nursing judgement supersedes pressure injury assessment tools.

1. Clean vs. sterile technique

Although little clinical data exist to support sterile technique over clean technique, questions persist. Frequently, providers specify “sterile” for routine dressing changes, which leads to confusion among clinicians. In 2011, the Wound, Ostomy and Continence Nurses Society® (WOCN®) published a fact sheet explaining what current evidence indicates. In 2018, Kent and colleagues also found no difference in wound infection rates when using clean or sterile techniques.

STAMP out skin tears: Skin tear assessment, management, and prevention

A guide for adhesive removal: Principles, practice, and products

According to the Centers for Disease Control and Prevention, only post-surgical wounds require a sterile dressing applied in the operating room. These dressings remain in place for 24 to 48 hours, after which they’re considered contaminated, eliminating the need for a sterile environment. The WOCN fact sheet states that clean technique is the most cost-effective approach to wound care and requires less time and fewer resources.

2. Hydrofiber vs. alginate

Although many think hydro­fiber and alginate dressings are interchangeable, significant differences exist. The fact that they’re similar in appearance only complicates distinguishing them from one another.

Alginates, derived from algae or brown seaweed, can absorb up to 20 times their weight. Hydrofiber dressings made from lab-created car­boxymethylcellulose, can hold 30 times their weight and present less risk of maceration than alginates, making them the preferred choice when managing wounds with copious amounts of drainage. Compound dressings that offer a mix of hydrofiber and alginate also are available. No evidence exists that compound dressing provides more efficacy than pure alginate or pure hydrofiber.

When selecting a dressing, consider the patient’s condition, wound drainage, and costs. Hydrofiber dressings cost slightly more than alginates but they last longer, which results in fewer dressing changes. They also can handle more drainage than alginates, making them a good option for heavily draining wounds. Always read the manufacturer’s guidelines before using advanced wound care products. (See Wound dressing examples. )

3. Negative pressure therapy and fistula management

The most recent edition of the WOCN Core Curriculum includes evidence-based, peer-reviewed guidelines regarding the use of negative pressure wound therapy (NPWT) to manage fistula output. The guidelines recommend considering NPWT for managing fistulas in open wounds if the fistula exhibits potential for closure and no exposed bowel is present. If management goals don’t include wound healing (or if healing isn’t possible), NPWT isn’t indicated.

The guidelines also state that fistula management should begin with the easiest approach and then to modify as necessary. The current gold standard begins with a pouching system, which is cost effective and provides greater patient mobility. If this option fails, other advanced modalities such as NPWT and suction may be considered, but only if the potential for closure exists.

4. Managing co-morbidities

Frequently, we select a dressing based on the premise it will heal a wound. However, patient condition and co-morbidities (such as diabetes, obesity, immune system dysfunction, malnutrition, cardiovascular disease, and cancer treatment) can prevent wound closure. A dressing provides an environment to help optimize wound healing, but if nutrition and co-morbidities aren’t managed appropriately, wounds will become chronic.

When conducting a thorough assessment, include medical history, medications, nutrition, and recent lab results. Also consider using a standardized assessment instrument, such as the validated Bates-Jensen Wound Assessment Tool. Certain medications, such as glucocorticoids, can interfere with wound healing, and abnormal lab markers (for example, glucose, glycated hemoglobin, and prealbumin) may indicate whether the patient’s nutrition status will support wound healing. Avoid tunnel vision when selecting a plan and consider the whole patient.

5. Pressure injury risk assessment tools

Many clinicians misunderstand and misuse pressure injury (PI) risk assessment tools, including the original Braden Scale, Norton Scale, and Waterlow Scale. These tools, which were developed over 30 years ago, don’t reflect current risk research and knowledge. We now understand that many factors (skin temperature, oxygenation, perfusion status, co-morbidities, age, blood tests, and medications) impact PI risk.

When the National Pressure Injury Advisory Panel addressed these tools and risk factors, they noted that, although structured PI risk assessment tools provide critical information, clinicians shouldn’t rely on the score alone. Nurses and other caregivers should use their professional judgement in conjunction with an assessment tool to formulate an accurate risk level for each patient.

Stay current and open-minded

Staying current with wound care best practices requires continuous effort. Take the time to read about new research and evidence to ensure you implement the most recent best practices. Stay open-minded and willing to change care approaches beneficial to patients.

American Nurse Journal. 2023; 18(2). Doi: 10.51256/ANJ022325;

Key words: wound care, hydrofiber dressings, alginate dressings, fistula, risk assessment

Carmel JE, Colwell JC, Goldberg MT, eds. Core Curriculum: Ostomy Management. 2nd ed. Fistula management. Philadelphia, PA: Wolters Kluwer; 2021.

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention of pressure injuries. In: Haesler E, ed. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline . EPUAP/NPIA/PPPIA. 2019.

Gibbs KA. Absorptive dressings: Alginates and hydrofibers. Advances in Wound Care . 20101:142-7.

Kent DJ, Scardillo JN, Dale B, Pike C. Does the use of clean or sterile dressing technique affect the incidence of wound infection? J Wound Ostomy Continence Nurs . 2018;45(3):265-9. doi:10.1097/WON.0000000000000425

Mahmoudi M, Gould LJ. Opportunities and challenges of the management of chronic wounds: A multidisciplinary viewpoint. Chronic Wound Care Manage Res . 2020;7:27-36 doi:10.2147/CWCMR.S260136

Mangram, A. J., Horan, T., Pearson, M. L., Silver, B. S., & Jarvis, W. R. (1999). Guideline for Prevention of Surgical Site Infection, 1999, 20, 247-248. Centers for Disease Control and Prevention. https://jamanetwork.com/journals/jamasurgery/fullarticle/2623725

Wound, Ostomy and Continence Nurses Society Wound Committee and the Association for Professionals in Infection Control and Epidemiology, Inc. Clean vs. sterile dressing techniques for management of chronic wounds: A fact sheet. J Wound Ostomy Continence Nurs. 2012;39(2 suppl):S30-4. doi:10.1097/WON.0b013e3182478e06

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Staebel K. Wound care: Five evidence-based practices. American Nurse Journal. 2023;18(2):25-27. doi:10.51256/anj022325 https://www.myamericannurse.com/wound-care-five-evidence-based-practices/

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Palliative Wound Care: Case Studies

Journal of Hospice and Palliative Nursing

February 2022, Volume 24 Number 1 , p 15 - 21

Earn 2 Contact Hours

home care , hospice wound care , palliative wound care , wound care

• Walsh, Anne ANP-BC, CWOCN, ACHPN

Patients with advanced illness may present to palliative care or hospice with unmanaged symptoms that may be exacerbated by the presence of a wound. The wound can be a constant reminder to the patient and caregiver of the underlying illness. Distressing symptoms such as wound pain, odor, bleeding, and/or excessive exudate may impede the patients' ability to spend quality time with loved ones when they need them the most. Although patients may present with wounds of varying etiologies, the most common wounds seen in this patient population are pressure-related injuries. However, there is a shortage of both wound and palliative specialized clinicians. Telehealth and the use of other technology can be a way to address this shortage. This will grant access to a broader number of patients to ensure appropriate wound care plans are in place to meet the goals of care. Although wound healing may not always be possible in this patient population, having access to specialized wound and palliative experts can improve the quality of life for patients and their caregivers.

Article Content

Although wound healing may not always be possible in the patient with advanced illness, there is much we can do as clinicians to alleviate patient and caregiver suffering. Kelechi et al 1 report that 47% of patients referred to hospice present with wounds, with up to half of those being pressure-related injuries. Jakobsen et al 2 found a pressure ulcer/injury incidence of 17.3% in cancer patients admitted to hospice. Other wound etiologies often seen in this patient population include malignant wounds, skin tears, vascular ulcers, Kennedy terminal ulcers, 3 autoimmune-related wounds such as bullous pemphigoid, and, more recently, COVID-19-related skin changes, to name a few. 4 Tilley et al 5 report that 14% of advanced cancer patients in the United States present with malignant fungating wounds. Skin tears are also commonly seen in the palliative and hospice patient population, especially with the older adults, because of risk factors such as age-related skin changes, mobility issues, medication side effects, and impaired nutrition. 6 The wound is often a reflection of an underlying disease entity such as with venous leg ulcers in the setting of advanced heart failure and lower extremity edema. See Figure 1 for a snapshot of typical wound etiologies consulted on by the certified wound, ostomy, and continence nurse practitioner (CWOC NP) during a course of a month at the author's home hospice facility.

Wound healing may not always be possible because of several factors including advanced disease, multiple comorbidities, poor nutrition, poor tissue perfusion, advanced age, and frailty. 7-10 Palliative wound care shifts the focus from healing to symptom management and uses an interdisciplinary team approach to address the whole person. This includes psychosocial and spiritual elements in addition to addressing the physical symptoms to improve the quality of life for patients and caregivers. The distressing wound symptoms may include pain, bleeding, odor, pruritis, and/or excessive wound exudate, which can lead to anxiety, embarrassment, and social isolation. It is important to set realistic expectations to avoid disappointment when wound healing may not be possible. Examples of this include, but are not limited to, a malignant wound where curative treatment is no longer appropriate or with a gangrenous limb where the patient is not a candidate for surgical intervention to restore the blood flow. 8

Caregivers may feel overwhelmed and have a sense of guilt if their loved one develops skin breakdown despite meticulous care and need the support of the whole team including the CWOC nurse/NP. The development of skin breakdown may reflect skin organ failure due to intrinsic versus extrinsic factors as the patient nears the end of life. 9-11 The skin being the largest organ of the body may fail along with other organs such the heart, lungs, and kidneys. It is important to keep the wound dressing regimen as simple as possible, so that more time can be spent with loved ones than on complicated wound care treatments. As Dr Beers 11 points out, less is more.

There may, however, be limited access to both specialized wound clinicians and specialized palliative care clinicians, and telehealth may be a way to increase access to these services. 12,13 The use of telehealth became more prevalent than ever during the COVID-19 pandemic. 14-16 Telehealth allows prioritization of necessary in-person specialist wound care visits. This includes visits to provide bedside sharp debridement, where appropriate, to quickly palliate symptoms of odor and excessive exudate that may result from the presence of necrotic tissue. Other necessary in-person visits may include assisting with complicated ostomy/fistula pouching situations and supporting overwhelmed caregivers and clinicians new to the field. Telehealth also allows for more timely consults while reaching a broader number of patients to ensure appropriate wound care plans are in place to meet the goals of care.

The telehealth consult can be initiated by sending wound pictures via secure emails or text messages to the wound specialized clinician, or the clinician may evaluate the wound in real time via platforms such as Zoom, FaceTime, and WhatsApp while other interdisciplinary team members are at the bedside.

Technology is also a way to put the necessary educational tools in the hands of the generalist clinician providing wound care to the frail patient with poor healing potential. The palliative wound educational gap prompted the author to launch a wound app. The app is currently named "Palliative Wound Pro" (with consideration of renaming it simply "Wound Pro" for it to be more inclusive). Although the goals of wound care may be different, the same general wound principles apply to all wounds. The wound etiology is addressed where feasible, and a clean, moist wound bed is maintained to increase the healing potential. An exception to this is dry, intact eschar in the frail patient with a poor healing potential. The dry eschar is considered a "protective shell" and is maintained dry to avoid opening it up. 17 The app is currently available as a free resource for clinicians to access wound care treatment options. It provides an overview of 8 wound etiologies commonly encountered in the palliative care and hospice patient population. It offers wound picture examples, wound treatment and symptom management options, case studies, documentation guidelines, and more.

The following 5 case studies demonstrate a palliative approach to wound care in the patient with advanced illness receiving home hospice care. These consults were completed via a combination of in-home CWOC NP visits along with telehealth consults initiated by the nurse, nurse practitioner, or physician visiting the home. These case studies demonstrate both healing in the first 3 case studies and improved symptom management in the last 2 case studies where healing was not possible, because of factors mentioned previously in this article.

CASE STUDY 1: SACRAL PRESSURE INJURY

A 96-year-old widowed woman with New York Heart Association class IV heart failure and multiple comorbidities, including diabetes mellitus type 2, hypertension (HTN), atrial fibrillation, and a chronic unstageable sacral pressure injury, presented to the hospital from a local nursing home because of heart failure exacerbation, pneumonia, and anoxic respiratory failure. Because of her heart failure exacerbation, multiple infections, worsening sacral pressure injury, and a decreased functional status, she was referred for hospice services. The patient and her daughter preferred her to return to her home of 60 years for end-of-life care. She was mainly bedbound and required total care. She enjoyed music therapy as provided by a volunteer.

The hospice intake nurse contacted the wound, ostomy, and continence (WOC) NP for an initial consult via FaceTime. The sacral pressure injury was considered an unstageable pressure injury because of the presence of necrotic tissue obscuring the full depth of injury. Her daughter was concerned that there was an odor.

The initial recommendations were to cleanse the sacral wound and periwound thoroughly with a wound cleanser spray, pat dry, and apply quarter strength (0.125%) sodium hypochlorite solution-moistened gauze to the area of necrosis. This was suggested to promote debridement of the necrotic tissue and to manage the odor by decreasing the microbial count. 18 Sodium hypochlorite solution is made from diluted bleach and has been used since World War I. 18 Wound cleanser sprays make it easy to thoroughly cleanse/irrigate a wound. The nozzle delivers the right amount of pressure to give the wound/periwound a good cleaning, without being too forceful, particularly if there is a cavity present. An alcohol-free skin barrier wipe was recommended to protect the periwound. Gauze was used to pad over the site, and an absorbent, waterproof, gentle silicone foam dressing was recommended to secure the dressing. This was completed 3 times weekly and as needed if it became soiled and was recommended short-term until the wound contained less necrotic tissue.

The WOC NP scheduled a home visit, within a few days of her hospice admission, to perform conservative bedside sharp debridement of the remaining necrotic tissue with patient/caregiver consent. The goal was to further palliate the symptoms of odor and excessive exudate. The patient was premedicated an hour before the visit with morphine 0.25 mL (5 mg) orally with good effect. The primary dressing was then changed to a calcium alginate 2 times weekly and as needed to manage the moderate amount of exudate and for its hemostatic properties due to bleeding episodes reported. 17,19

After a few weeks of using the calcium alginate, the exudate amount decreased, and the wound treatment was changed to a hydrogel 2 times weekly and as needed to maintain a moist wound bed to increase the healing potential. This was used until the wound healed. Once it healed, the caregivers were encouraged to use a moisture barrier agent to the site with incontinent care and to continue to offload pressure to decrease the risk of a recurrence. As the wound characteristics changed, the treatment was changed (see Figure 2 ).

Pressure injury prevention measures were continually reinforced to address the underlying etiology. This included placing a support surface on her bed (a group 1 support surface was used; eg, an alternating pressure pad overlay). She was not receptive to an external catheter to manage her urinary incontinence. In addition to the nursing and medical staff, the interdisciplinary team included a physical therapist, a social worker, a spiritual care counselor, the registered dietician, a volunteer support, and a home health aide. The patient and her daughter appreciated the support from all the team members to make home hospice possible for her.

CASE STUDY 2: RIGHT ARM SKIN TEAR

The patient was an 81-year-old married woman with small cell lung cancer, coronary artery disease, and vascular dementia. She was a retired teacher and enjoyed her spouse reading to her. During her months on hospice, she developed a mass behind her right ear that continued to grow and developed skin tears at her extremities. The skin tears at her arms were described as "opening and closing." The skin tear shown here was reported as occurring when a family member was assisting her from the bed to the chair and she bumped her arm (see Figure 3 ). The patient and caregiver agreed to discontinue her oral aspirin 81 mg taken daily because of the extensive bruising at her skin and bleeding from her wounds. This symptom was very frightening for them, and the burden likely outweighed the benefits of aspirin at this stage. Both the patient and her son became anxious as they saw her skin bruising easily and the episodes of profuse wound bleeding. It had become a constant source of worry for them. Furthermore, although they understood she had been taking aspirin for many years as a preventative measure for a cerebral vascular accident and myocardial infarction, they preferred to discontinue it to decrease her bleeding risk.

The skin tear was cleansed gently with a wound cleanser spray and patted dry, the partial skin flap was approximated where possible, and a petrolatum gauze with bismuth was applied to the site. This was covered with an abdominal pad and secured with a gauze wrap twice weekly. This dressing was chosen for its nonadherent 20 and antibacterial properties and because it could be left in place for several days. Meticulous skin care was reinforced. Bumper pads were provided for her hospital bed side rails to decrease the risk of further injury. Her skin tear went on to heal, and the malignant mass bled less. She was very spiritual and felt great solace with regular spiritual care support. Her son felt less anxious and more able to cope with her illness, seeing her more relaxed and at peace.

CASE STUDY 3: VENOUS LEG ULCERS (BILATERAL LOWER EXTREMITIES)

The patient is a 95-year-old widowed woman with New York Heart Association class IV heart failure, HTN, and extensive osteoporosis. Because of decreased functional status, worsening heart failure, renal failure, chronic nonhealing bilateral lower extremity venous leg ulcers, and increased frailty, she was referred to hospice. Her symptoms included pain at the wound sites exacerbated with wound care and dyspnea with minimal exertion. She was receiving supplemental oxygen 3 L/min via nasal cannula as needed for shortness of breath. Her legs were edematous (about 3+ nonpitting edema). Because of a typical low blood pressure of 88/60 mm Hg, she was unable to tolerate increasing her diuretics despite the edema and bilateral pulmonary crackles. Methadone 2.5 mg (0.25 mL) orally twice daily worked well to manage her pain and dyspnea. Her son lived out of town but visited and called frequently. She had a 24-hour live-in aide as she became more debilitated. She enjoyed pet therapy as provided by the volunteer department. She always had dogs, and this brought her tremendous joy to be able to interact with the therapy dog.

Wound cleanser spray was used to cleanse the lower extremity wounds and periwounds, and ammonium lactate lotion was used to her dry skin. Initially, a calcium alginate was used to the sites for increased absorbency along with abdominal pads secured with a gauze wrap. A tubular compression bandage was applied over the dressing from the base of her toes up to about an inch below her knees for light compression therapy. This was used to manage the edema, to increase the healing potential, and to decrease the risk of cellulitis while avoiding sending excess fluid back to her heart and exacerbating her heart failure. This treatment was performed 3 times weekly for a few weeks. Compression therapy is the standard of care for the treatment of venous leg ulcers when tolerated. 21

On a follow-up CWOC NP visit, honey wound gel was added for its antimicrobial effects and to promote autolytic debridement of the yellow fibrin slough tissue at her right leg ulcer as the area had become tender. Over time, as the exudate decreased further, the primary dressing was changed to a petrolatum gauze with bismuth twice weekly, which is also antimicrobial but nonadherent now that the exudate amount was minimal.

The wounds and the edema decreased greatly during the course of about 2 weeks. She was not open to podiatry services for nail care. Meticulous skin care and the importance of ongoing compression therapy, as tolerated, were reinforced because of the high risk for cellulitis with the presence of edema. Her wounds went on to heal, and this treatment helped keep her as functional as possible in her home (see Figure 4 ).

CASE STUDY 4: RIGHT FOOT GANGRENE

The patient is an 88-year-old widowed man with advanced Alzheimer disease, atherosclerosis, type 2 diabetes mellitus, HTN, renal failure, and peripheral vascular disease with gangrene to his right foot. He had 1 daughter who was very devoted. He was referred to hospice from a certified home care agency for end-of-life care. His daughter wanted comfort care per her father's known wishes and refused an amputation. Initially, the right great toe and right fifth toe were gangrenous, but over time as the disease progressed, it included all his right foot toes and his instep. The area was painful with wound care as noted by nonverbal cues and had a faint odor at times. Pain was managed with oral methadone 2.5 mg twice daily and oxycodone/acetaminophen 5/325 mg administered 2 to 3 times daily for breakthrough pain.

The wound treatment had been daily application of silver sulfadiazine cream to the gangrenous toes. This was discontinued to avoid converting the dry gangrene to a wet gangrene from the application of a moist agent, which would promote autolytic debridement (use of the body's own natural enzymes). Instead of this, a drying antimicrobial agent, povidone iodine, was used to paint the necrotic tissue to decrease the microbial count. 17 The area was gently cleansed with a wound cleanser spray, or if any odor was present, 1/4-strength sodium hypochlorite solution was used to cleanse the affected areas. It was then covered with abdominal pads secured loosely with a gauze wrap 2 times weekly. This regimen worked well in managing the odor and keeping the necrotic tissue intact. His daughter also wanted to trial a course of antibiotics to see whether it would help the odor and slow the disease progression. He was initially tolerating aspirin 81 mg daily orally as an antiplatelet agent in the hopes of improving the blood flow. Although the disease progressed despite the interventions, the distressing symptoms were managed at home through the support of the interdisciplinary team until his death a few weeks later. The CWOC NP consults were completed both in-person and via secure texts sent by the nurse visiting the home (see Figure 5 ).

CASE STUDY 5: LEFT ANTERIOR AND POSTERIOR MALIGNANT CHEST WOUNDS

This patient is an 82-year-old single woman with endometrial cancer diagnosed about a year ago. She underwent a hysterectomy and received chemotherapy at that time. Her comorbidities included type 2 diabetes mellitus and HTN. She was alert and oriented x3 and tried to maintain her independence as much as possible. She was a retired accountant and took pride in being very organized. Her sister was her main caregiver, and the local chaplain was very supportive. She had volunteered in her church for many years after retirement. She had a recent hospitalization for wound bleeding, and at that time, her aspirin was discontinued. She had been receiving certified home care agency services for wound care, but after this hospitalization, she was referred to home hospice. She presented to hospice with extensive chest cutaneous metastases from the endometrial cancer. She denied pain, but she and her caregivers were distressed by the odor and bleeding. The WOC NP provided both in-person and telehealth consults. The wound care was initially to cleanse with wound cleanser and apply abdominal pads daily.

With the initial WOC NP consult, the treatment was changed to gently cleanse with wound cleanser spray or hypochlorous acid solution as needed odor, pat dry, and apply a petrolatum gauze with bismuth to the sites to prevent adherence to the friable tissue. This was recommended as the current dressing was adhering and causing bleeding with dressing changes. A skin barrier film was recommended to protect the periwounds. Abdominal pads were recommended as the secondary dressing, and a gentle silicone tape was suggested to secure the dressing 2 times weekly and as needed (she was not interested in a mesh net dressing retainer). Less frequent dressing changes were suggested to decrease the risk of bleeding and potential pain with dressing changes. Metronidazole 1% spray was ordered to the site as needed for odor management with dressing changes with good effect. 17,19,22 For the bleeding, oxymetazoline nasal spray, off-label, was sent from the hospice pharmacy to apply to the site as needed for bleeding with dressing changes. 17 It works as a vasoconstrictor within approximately 10 minutes and lasts up to 12 hours. Because of several areas of bleeding and the potential for burning pain with the use of silver-nitrate sticks, this option was chosen. The odor and bleeding improved, but over time, there was some strike-through exudate soiling her garments. The treatment was then changed to a silicone foam dressing with silver for increased absorbency and odor management twice weekly and as needed. The WOC NP also considered a calcium alginate, a hydrofiber, or a chitosan-based gelling fiber with silver for odor management, hemostasis, and increased absorbency. The patient wished to trial the silver foam option first when samples were shown to her. This regimen worked well for her and her caregivers. With her family around her, she was able to maintain her independence at home until she passed away peacefully 3 weeks later (see Figure 6 ).

In conclusion, although patients with advanced disease and wounds may present with poor healing potential, there is much we can do as clinicians to ease the suffering that may be brought on by wounds. Although the same general wound principles apply to all wounds, the goals of care may differ when it comes to palliative wound care. Although there is a scarcity of wound and palliative specialized clinicians, educational technology in the hands of the generalist clinician is one way to empower them to care for these patients. Telehealth is another effective way for specialized clinicians to reach a broader, underserved population, in addition to serving as a resource for colleagues to provide wound consults and the education necessary to meet the goals of care.

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2. Jakobsen TBT, Pittureri C, Seganti P, et al. Incidence and prevalence of pressure ulcers in cancer patients admitted to hospice: a multicentre prospective cohort study. Int Wound J . 2020;17(3):641-649. doi:. [Context Link]

3. Ayello EA, Levine JM, Langemo D, Kennedy-Evans KL, Brennan MR, Sibbald RG. Reexamining the literature on terminal ulcers, SCALE, skin failure, and unavoidable pressure injuries. Adv Skin Wound Care . 2019;32(3):109-121. doi:. [Context Link]

4. Howell M, Loera S, Tickner A, et al. Practice dilemmas: conditions that mimic pressure ulcers/injuries-to be or not to be? Wound Manag Prev . 2021;67(2):12-38. doi:. [Context Link]

5. Tilley CP, Fu MR, Qiu JM, et al. The microbiome and metabolome of malignant fungating wounds: a systematic review of the literature from 1995 to 2020. J Wound Ostomy Continence Nurs . 2021;48(2):125-135. doi:. [Context Link]

6. Strazzieri-Pulido KC, Picolo Peres GR, Goncalves Faustino Campanili TC, Conceicao de Gouveia Santos VL. Incidence of skin tears and risk factors: a systematic literature review. J Wound Ostomy Continence Nurs . 2017;44(1):29-33. doi:. [Context Link]

7. Mahmoudi M, Gould LJ. Opportunities and challenges of the management of chronic wounds: a multidisciplinary viewpoint. Chronic Wound Care Manage. Res . 2020;7:27-36. doi:. [Context Link]

8. Vickery J, Compton L, Allard J, Beeson T, Howard J, Pittman J. Pressure injury prevention and wound management for the patient who is actively dying: evidence-based recommendations to guide care. J Wound Ostomy Continence Nurs . 2020;47(6):569-575. doi:. [Context Link]

9. Pittman J, Beeson T, Dillon J, et al. Hospital-acquired pressure injuries and acute skin failure in critical care. A case-control study. J Wound Ostomy Continence Nurs . 2021;48(1):20-30. doi:. [Context Link]

10. Solmos S, LaFond C, Pohlman AS, Sala J, Mayampurath A. Characteristics of critically ill adults with sacrococcygeal unavoidable hospital-acquired pressure injuries: a retrospective, matched, case-control study. J Wound Ostomy Continence Nurs . 2021;48(1):11-19. doi:. [Context Link]

11. Beers EH. Palliative wound care: less is more. Surg Clin North Am . 2019;99(5):899-919. doi:. [Context Link]

12. Rogers LC, Armstrong DG, Capotorto J, et al. Wound center without walls: the new model of providing care during the COVID-19 pandemic. Wounds . 2020;32(7):178-185. [Context Link]

13. Abbott J, Johnson D, Wynia M. Ensuring adequate palliative and hospice care during COVID-19 surges. JAMA . 2020;324(14):1393-1394. doi:. [Context Link]

14. Mahoney MF. Telehealth, telemedicine, and related technologic platforms. Current practice and response to the COVID-19 pandemic. J Wound Ostomy Continence Nurs . 2020;47(5):439-444. doi:. [Context Link]

15. Engels D, Austin M, Doty S, Sanders K, McNichol L. Broadening our bandwidth: a multiple case report of expanded use of telehealth technology to perform wound consultations during the COVID-19 pandemic. J Wound Ostomy Continence Nurs . 2020;47(5):450-455. doi:. [Context Link]

16. Ratliff CR, Shifflett R, Howell A, Kennedy C. Telehealth for wound management during the COVID-19 pandemic. Case studies. J Wound Ostomy Continence Nurs . 2020;47(5):445-449. doi:. [Context Link]

17. Brinker J, Protus B, Kimbrel J. Wound Care at End of Life: A Guide for Hospice Professionals . 2nd ed. Montgomery, AL: Optum Hospice Pharmacy Services; 2018. [Context Link]

18. Keyes M, Jamal Z, Thibodeau R. Dakin Solution . Treasure Island, FL: StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK507916/ . Updated July 31, 2021. Accessed September 27, 2021. [Context Link]

19. Ferris F, Von Gunten CF. Malignant Wounds . 2nd ed. https://www.mypcnow.org/fast-fact/malignant-wounds/ . Updated May 2015. Accessed September 27, 2021. [Context Link]

20. LeBlanc K, Langemo D, Woo K, Hevia Campos HM, Santos V, Holloway S. Skin tears: prevention and management. Br J Community Nurs . 2019;24:S12-S18. doi:. [Context Link]

21. Rajhathy EM, Murray HD, Roberge VA, Woo KY. Healing rates of venous leg ulcers managed with compression therapy. J Wound Ostomy Continence Nurs . 2020;47(5):477-483. doi:. [Context Link]

22. Crumley C. A breath of fresh air: odor management to maintain patient dignity: a view from here. J Wound Ostomy Continence Nurs . 2021;48(4):359-361. doi:. [Context Link]

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Evidence-Based Care of Acute Wounds: A Perspective

Dirk t. ubbink.

1 Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.

Fleur E. Brölmann

2 Department of Surgery, Lucas Andreas Hospital, Amsterdam, The Netherlands.

Peter M. N. Y. H. Go

3 Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.

Hester Vermeulen

4 School for Health Professions, Amsterdam, The Netherlands.

Significance: Large variation and many controversies exist regarding the treatment of, and care for, acute wounds, especially regarding wound cleansing, pain relief, dressing choice, patient instructions, and organizational aspects.

Recent Advances: A multidisciplinary team developed evidence-based guidelines for the Netherlands using the AGREE-II and GRADE instruments. A working group, consisting of 17 representatives from all professional societies involved in wound care, tackled five controversial issues in acute-wound care, as provided by any caregiver throughout the whole chain of care.

Critical Issues: The guidelines contain 38 recommendations, based on best available evidence, additional expert considerations, and patient experiences. In summary, primarily closed wounds need no cleansing; acute open wounds are best cleansed with lukewarm (drinkable) water; apply the WHO pain ladder to choose analgesics against continuous wound pain; use lidocaine or prilocaine infiltration anesthesia for wound manipulations or closure; primarily closed wounds may not require coverage with a dressing; use simple dressings for open wounds; and give your patient clear instructions about how to handle the wound.

Future Directions: These evidence-based guidelines on acute wound care may help achieve a more uniform policy to treat acute wounds in all settings and an improved effectiveness and quality of wound care.

Dirk T. Ubbink, MD, PhD

Scope and Significance

F or chronic wounds , such as venous, arterial, pressure, and diabetic foot ulcers, several (inter)national guidelines are available. 1 For wounds with an acute etiology, fewer guidelines exist. Still, an undesirable inconsistency in wound care practice is evident from the huge number of wound dressings available, the large number of caregivers involved, and the many opinions regarding optimum wound care. 2 This calls for more evidence-based and more uniform care to avoid undesired variation in care.

Translational Relevance

In terms of translational research, available guidelines have focused on diminishing barriers for wound healing given certain comorbid conditions, 3 or have described inconsistencies in the documentation of surgical wound care according to existing guidelines, mainly regarding the prevention and treatment of surgical site infections, which hamper interdisciplinary communication. 4

Clinical Relevance

Current clinical guidelines on acute wound care comprise the CDC guideline, 1999; the NICE clinical guideline 74, 2008; the SQuIRe 2 CPI Guide, 2009; the EWMA Position Statement (2006); and the AWMA Standards (2011). 4 Most of these guidelines have become outdated. This article describes the development of relevant guidelines for all medical and nursing professionals and stakeholders involved in wound care in any care setting, and summarizes the most noticeable and practical recommendations in five areas: wound cleansing, pain relief, dressing choice, patient instructions, and organizational aspects.

The present guidelines were developed to provide advisable and practical options for acute-wound care to promote more uniformity, effectiveness, and quality in the care for acute wounds after surgery or trauma. Guidelines development started in January 2012. The first draft of the guidelines was produced in February 2013. Feedback from the reviewers was collected and incorporated in the guidelines in July 2013. The final guidelines were authorized by all contributing professional societies in November 2013.

The development was conducted in the Netherlands along the AGREE-II instrument, 5 and by involving all relevant professional societies in a working group (the members are stated in “Acknowledgments” section). We also made an inventory of experiences of patients treated for their acute wounds in the emergency room. This has been instrumental to incorporate their insights and preferences in the recommendations of this guideline.

First, the expert members of the working group made an inventory of the most common controversies in clinical practice. Input for this inventory came from the results of calls in Dutch nursing journals and during a nursing conference to submit important issues as perceived by caregivers in the field. Next, the working group scored the urgency and significance of these controversies. The five highest-scoring topics were chosen to address in this guideline.

Evidence for each topic was derived from a systematic review of the literature and judged using the GRADE method. 6 Preferably, studies that focused on validated, patient-relevant outcomes were used. The resulting conclusions were presented to the members of the working group to formulate recommendations based on the evidence and other professional, practical, cost, or patient-related considerations.

The concept guidelines have been scrutinized by 18 independent members of 12 professional societies, not necessarily participating in the working group. The working group has considered and incorporated these remarks in the final version. 7 The guidelines were subsequently authorized by the participating professional societies and were added to their official Web sites. The guidelines were initiated by the Dutch Surgical Society, who will decide about an update not later than in 2019. A summary of the five most important issues has been used for the Dutch “Choosing Wisely” campaign ( Fig. 1 ).

Critical directions from the guidelines, as summarized in the Dutch “Choosing wisely” campaign. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

The guidelines contain a total of 38 recommendations, based on best available evidence, additional expert considerations, and patient experiences. 8 A full listing of the recommendations is given in Table 1 . The strength of the evidence is expressed according to the GRADE classification, 5 including high- , moderate- , low- , and very-low -quality evidence. In the absence of evidence, the expert opinion of the working group ( WG ) was adopted.

Overview of the recommendations

Which wounds should be cleansed and how?

• • Wounds that are closed under aseptic conditions do not require further cleansing and disinfection, because available evidence shows that this does not lead to lower infection rates ( moderate ), 7 but does cost time and money ( WG ).
• • Cleanse open wounds healing through secondary intention with drinkable tap water ( moderate ), 8 if contaminated ( e.g ., street wounds, bite wounds, or cut wounds) in a patient-friendly way using lukewarm water, by means of gentle irrigation ( WG ). Only after adequate cleansing and in a later stage of wound healing can antiseptics like (povidone-)iodine or honey be useful for locally infected wounds ( WG ). The use of disinfectants is dissuaded ( low ), 9 , 10 particularly the bathing of feet or hands in detergents ( e.g ., soda, washing powder, or shower gel), as it macerates the skin, fosters infection, delays healing, and encumbers the patient ( WG ).

How to treat wound pain?

Flow chart showing the various options for analgesic treatment of wound pain. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

• • Apply infiltration anesthesia with lidocaine or prilocaine. Topical application is an alternative if the patient is afraid of needles, but the time before it takes effect has to be considered (30–45 min) ( low ). 11 EMLA ® cream is recommended only when applied following the official instructions, that is, on intact skin or venous ulcers ( WG ). Do not use nonsteroid anti-inflammatory drug (NSAID)–containing dressings as their effectiveness has not been shown and they are costly and may cause side effects ( moderate ). 12
• • Treat mild and moderate pain (VAS scores between 1 and 6) during dressing changes with paracetamol or NSAIDs ( high ), 13 but be cautious when prescribing NSAIDs for patients >70 ( WG ). Moderate or severe pain (VAS scores 3–10) should be treated with opioids, such as morphine or fentanyl ( high ). 13
• • Use the WHO pain ladder to choose a suitable analgesic to treat pain between dressing changes ( WG ). 14 This should be decided in consultation with the patient ( WG ).

What wound dressing material for which wound?

Flow chart showing the various cleansing, dressing, and topical agent options for acute-wound care. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

• • Leave a closed, dry wound uncovered because covering does not reduce the infection risk, while dressing changes can be painful. 15–18 A wound dressing may be used to absorb wound fluid or blood and if desired by the patient, for example, to avoid friction with clothes. A conventional nonadhesive gauze dressing or plaster usually suffices for this purpose and saves costs ( WG ).
• • Apply a nonadhesive (silicone or paraffin gauze) dressing to secondarily healing wounds ( low ), as these are most suitable in terms of wound healing time, infection risk, and pain. 11 , 19 Small or superficial acute wounds may dry uncovered ( WG ). The dressing choice should depend on the circumstances of the patient and wound (change frequency, leakage, and pain) ( WG ). Leaking wounds may need more absorbing products or devices (foam, alginate, hydrofiber, or negative-pressure wound therapy). When leakage is substantial, its cause should be investigated ( WG ).
• • Use a hydrocolloid dressing to cover donor site wounds after split-skin grafting, or a film dressing as second best choice ( moderate ). 20
• • A nonadhesive dressing should be used for skin tears or skin flap wounds, only after proper cleansing and fixation ( WG ). The dressing should remain in situ for at least 7 days. If a skin flap has been removed, then a nonadhesive dressing can be applied and remain there for as long as possible ( WG ).

How should patients be instructed to take care of their wound?

• • Instruct patients about what to expect regarding normal wound healing as well as alarm symptoms, that is, signs of infection or complications ( WG ).
• • Provide patients with the name(s) and address(es) of the contact person(s) they can reach in case of questions or problems ( WG ).
• • Briefly showering the wound or bathing is allowed, if the patient wishes, within 12 h after wound closure in the primary care setting ( moderate ), 21 after 24 h in the hospital setting ( moderate ), 7 and after 48 h in case of underlying prosthetic material if the treating surgeon agrees ( WG ). This does not increase the infection risk. Longer showering or bathing (>10 min) unnecessarily increases the risk of skin maceration.
• • Surgeons should instruct their own patients regarding when and how to mobilize ( WG ). This is determined by the wound location, the expected healing tendency, the performed procedure, as well as the patient's preference and ability to mobilize.
• • Superficial acute wounds ( e.g ., grazes) may best be protected against ultraviolet light exposure for at least 3 months to avoid pigmentation differences and impairment of wound healing ( WG ). 22 , 23

How can the organization of the chain of wound care be improved?

• • When a patient is referred from one healthcare professional to another, at least the following items should be communicated to ensure optimum continuity of care: wound characteristics, healing progress, patient characteristics and comorbidity, treatment plan, and goals to be reached ( WG ).
• • A standard wound classification scheme should be used ( e.g ., Red-Yellow-Black and TIME) ( WG ). 24 , 25
• • It should be made clear to patients and colleagues who carries the responsibility for diagnostic and therapeutic actions and how to contact this person ( WG ).
• • These items should preferably be documented by using a uniform handover form ( WG ).

Implementation

The guidelines were developed in the Netherlands by all relevant stakeholders in wound care, including healthcare insurers. The relevant evidence available worldwide was merged with considerations of applicability, generalizability, and patient preferences to answer critical issues in clinical practice. The guideline's relevance lies in offering a document with a more uniform policy for the treatment of acute wounds in all settings by all caregivers involved, to improve the effectiveness and quality of wound care. The guidelines may also be useful as a primer for other countries to formulate their own, adapted to their local context, for example, by using the ADAPTE instrument. 26

Acute wounds form a frequent, global disorder with global controversies. A huge number of dressing materials is available within the European territory. Invariably, the organization of care is multidisciplinary in every country. Hence, (most of) the recommendations are likely to be applicable in many other countries as well.

The guidelines were highly desired because of the existence of a large, undesirable variation in care, the large number of care professionals involved, wound care products available, and patients in different settings who are confronted with acute wounds, that is, after surgery or trauma. The current undesirable practice variation seems due to the wide range of healthcare professionals involved in wound care and the countless wound care products marketed by many manufacturers over the last decades. Also, the current strength of the evidence base in wound care shows room for improvement. 27 , 28 These circumstances hamper guideline implementation.

To facilitate guideline uptake we involved representatives of virtually all relevant Dutch medical and nursing professional societies, as well as the national association of healthcare insurers, who joined forces to develop and implement this guideline. Apart from these professional societies, also the Dutch Societies of Paediatric Surgeons and Wound Care Professionals have provided feedback on the concept guideline. We recommended a multifaceted implementation strategy comprising electronic decision support, audit and feedback loops, and local opinion leaders to effectively change today's behavior of all wound care professionals. 29 The current implementation and application in local protocols will generate more feedback that will help fine-tuning future updates of the guideline.

Limitations

As limitations of this guideline development project, the guidelines obviously could not possibly encompass all issues involved in wound care. Other relevant but lower-scoring topics—for example, when to apply wet dressings or antibiotics, the best treatment of a fingertip trauma, the value of skin glue or negative-pressure wound therapy, and scar prevention—were documented to be included in future updates of the guideline. In the next update, an inventory should be made anew of critical issues to be addressed at that time.

Second, the guidelines were developed in a single country. Therefore, not all of the recommendations may be applicable or acceptable to other (even European) countries. In fact, even in the Netherlands, some recommendations are being accepted reluctantly, despite the acknowledged importance of such a document. Some old habits die hard. However, this holds for many other guidelines published in medical journals or clearinghouses on the Internet. The recommendations are supported by evidence from international publications, as well as by general medical and surgical principles. Even though not acceptable as a blanket policy standard, the guidelines presented here will hopefully at least be useful as a resource for national guidelines and local protocols anywhere.

An undesirable inconsistency in wound care practice is due to a huge number of wound dressings available, the large number of caregivers involved, and the many opinions regarding optimum wound care. As to acute wounds, few guidelines have yet been published. The evidence-based guidelines on acute wound care presented here may help achieve a more uniform policy to treat acute wounds in all settings and an improved effectiveness and quality of wound care.

TAKE-HOME MESSAGES

• • A multidisciplinary team developed guidelines to provide practical recommendations for acute wound care in order to render more uniformity, effectiveness, and quality in the care for acute wounds after surgery or trauma.
• • The guidelines address five controversial issues: wound cleansing, pain relief, dressing choice, patient instructions, and organizational aspects ( Fig. 1 ).
• • The guidelines present 38 recommendations and 2 flowcharts, based on best available evidence, additional expert considerations, and patient experiences.

Abbreviations and Acronyms

Acknowledgments and Funding Sources

The authors are indebted to the 18 independent members of 12 professional societies who critically reviewed the concept guidelines, as well as the members of the guideline development working group: Dr. F.E. Brölmann, MD, PhD (project executor); Dr. D.T. Ubbink, MD, PhD (project leader); Dr. H. Vermeulen, RN, PhD (chairperson); Mrs. P.E. Broos-van Mourik, MSc, Society of Nursing and Care Professionals (V&VN); Dr. P.M.N.Y.H. Go, MD, PhD, Dutch Surgical Society (NVvH); Mrs. E.S. de Haan, RN, Dutch Society of Emergency Care Nurses (NVSHV); Mr. M.W.F. van Leen, Association of Elderly Care Physicians and Social Geriatricians (Verenso); Mr. J.W. Lokker, Association of Healthcare Insurers (ZN); Dr. C.M. Mouës-Vink, MD, PhD, Dutch Society for Plastic Surgery (NVPC); Dr. K. Munte, MD, Dutch Society for Dermatology and Venereology (NVDV); Mr. P. Quataert, MSc, Society of Nursing and Care Professionals (V&VN); Dr. K. Reiding, MD, Dutch College of General Practitioners (NHG); Dr. E.R. Schinkel, MD, General Practitioner; Mrs. K.C. Timm, RN, Woundcare Consultant Society (WCS Kenniscentrum Wondzorg); Dr. M. Verhagen, MD, Dutch Society of Emergency Medicine Physicians (NVSHA); Dr. M.J.T. Visser, MD, Dutch Surgical Society (NVvH); Mr. T.A. van Barneveld, MSc, Association of Medical Specialists (OMS).

Further, we like to thank Prof. Dr. B.E. Sumpio, Professor of Surgery and Radiology, Yale University School of Medicine, New Haven; Prof. Dr. Z.E. Moore, Professor and Head of the School of Nursing and Midwifery, RCSI School of Nursing, Dublin, Ireland; and Prof. Dr. K.F. Cutting, Principal Lecturer in Tissue Viability, Buckinghamshire New University, Uxbridge, United Kingdom, for their valuable comments.

The development of these guidelines was sponsored by the Dutch Society of Surgeons and the Netherlands Organisation for Health Research and Development.

Author Disclosure and Ghostwriting

There are no competing financial interests. The contents of this article were expressly written by the authors listed. No ghostwriters were used to write this article.

About the Authors

Dirk Ubbink, MD, PhD, is a research physician and clinical epidemiologist. He is a principal investigator at the Department of Surgery in the Academic Medical Center at the University of Amsterdam. Fleur Brölmann, MD, PhD, is a surgery resident in training to become a plastic surgeon. Peter Go, MD, PhD, is a surgeon at the St. Antonius Hospital and chairman of the guidelines committee of the Dutch Society of Surgeons. Hester Vermeulen, RN, PhD, is a nurse and senior researcher at the Department of Surgery and member of the faculty of lecturers of the School for Health Professions at the University of Amsterdam.

Wound Care: A Comprehensive Guide for Nurses

This article was written in collaboration with Christine T. and ChatGPT, our little helper developed by OpenAI.

Wound care is the process of managing and promoting the healing of various types of wounds, such as surgical incisions, pressure ulcers, and traumatic injuries. It involves assessment, treatment, and prevention strategies tailored to the specific needs of each patient, with the goal of minimizing pain, infection, and complications while optimizing healing.

Related Terms

• Debridement: The removal of nonviable tissue, debris, and foreign materials from a wound to promote healing and reduce the risk of infection.
• Pressure ulcer : A localized injury to the skin and/or underlying tissue, usually over a bony prominence, resulting from prolonged pressure or pressure combined with shear and/or friction.
• Wound dressing: A sterile material applied directly to a wound to protect it, absorb exudate, and maintain a moist environment conducive to healing.

Synonyms, Definitions, and Examples

Assessment Techniques and Tools

Wound assessment techniques and tools include:

• Visual inspection of the wound, noting its size, depth, color, and presence of exudate or necrotic tissue.
• Palpation to assess for pain, tenderness, warmth, or induration, which may indicate infection or other complications.
• Measurement of the wound dimensions, using a ruler or wound measurement tool, to track changes in size over time.
• Evaluation of the surrounding skin and tissue for signs of inflammation, maceration, or other abnormalities.
• Assessment of the patient’s overall health, including nutritional status, comorbidities, and risk factors that may impact wound healing.
• Documentation of the wound assessment findings using standardized tools or forms, such as the Pressure Ulcer Scale for Healing (PUSH) Tool or the Bates-Jensen Wound Assessment Tool.

Assessment Frameworks

Several wound assessment frameworks are used by healthcare professionals to guide the evaluation and management of wounds. Some of these frameworks include:

• TIME: Tissue management, Infection or inflammation control, Moisture balance, and Epithelial edge advancement. This framework helps guide the assessment and treatment of chronic wounds.
• Wound, Ischemia, and foot Infection (WIfI) classification system: This system is used to classify the severity of diabetic foot ulcers and guide treatment decisions.
• Wound bed preparation: This concept involves assessing and managing the wound environment, including debridement, bacterial balance, and moisture management, to optimize healing.

Assessment Documentation

Proper documentation of wound assessments is essential for monitoring healing progress, guiding treatment decisions, and facilitating communication among healthcare providers. Key aspects of wound assessment documentation include:

• Describing the wound’s location, size, depth, and appearance, including the presence of exudate or necrotic tissue.
• Documenting the patient’s pain level, using a standardized pain assessment scale.
• Recording any interventions performed, such as wound cleansing, debridement, or dressing application, along with the patient’s response to these interventions.
• Noting any patient education provided regarding wound care, prevention strategies, or self-management techniques.
• Updating the patient’s care plan as needed based on the wound assessment findings and the patient’s overall health status.

Legal and Ethical Considerations

Legal and ethical considerations in wound care include:

• Adhering to evidence-based practice guidelines and professional standards for wound assessment, treatment, and prevention.
• Respecting patient autonomy and obtaining informed consent before performing any wound care interventions.
• Maintaining patient confidentiality and adhering to privacy regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) , when documenting and sharing wound assessment information.
• Advocating for patient needs, including appropriate resources and referrals for specialized wound care services if needed.
• Continuously updating knowledge and skills related to wound care through ongoing education and professional development.

Real-Life Examples or Case Studies

Case studies in wound care provide valuable insights into the complex process of wound assessment and management, highlighting the importance of a comprehensive and individualized approach. Examples include:

• A patient with a chronic venous leg ulcer that improves with compression therapy, wound cleansing, and moisture-retentive dressings.
• A patient with a diabetic foot ulcer requiring debridement, offloading, and close monitoring of blood glucose levels to promote healing.
• A patient with a pressure ulcer that resolves through a combination of repositioning, pressure redistribution surfaces, and appropriate wound dressings.
• A patient with a surgical wound experiencing delayed healing due to infection, which is successfully managed with antibiotic therapy and wound care interventions.
• A patient with a traumatic injury requiring a multidisciplinary approach to wound care, including surgical intervention, nutritional support, and psychological counseling.

Resources and References

For further learning and professional development in wound care, consider the following resources:

• Wound, Ostomy, and Continence Nurses Society (WOCN): https://www.wocn.org/
• WoundSource: https://www.woundsource.com/
• Journal of Wound, Ostomy, and Continence Nursing (JWOCN): https://journals.lww.com/jwocnonline/pages/default.aspx
• Wound Care Education Institute (WCEI): https://www.wcei.net/

Wound care is an essential aspect of nursing practice, requiring a comprehensive and patient-centered approach to assessment, treatment, and prevention. By staying up-to-date on the latest evidence-based practices, adhering to legal and ethical principles, and utilizing available resources, nurses can play a vital role in optimizing patient outcomes and promoting healing.

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Palliative Wound Care

Case studies.

Walsh, Anne ANP-BC, CWOCN, ACHPN

Anne Walsh, ANP-BC, CWOCN, ACHPN, is Visiting Nurse Service of New York Hospice & Palliative Care.

Address correspondence to Anne Walsh, ANP-BC, CWOCN, ACHPN, Visiting Nurse Service of New York Hospice & Palliative Care ( [email protected] ).

Patients with advanced illness may present to palliative care or hospice with unmanaged symptoms that may be exacerbated by the presence of a wound. The wound can be a constant reminder to the patient and caregiver of the underlying illness. Distressing symptoms such as wound pain, odor, bleeding, and/or excessive exudate may impede the patients' ability to spend quality time with loved ones when they need them the most. Although patients may present with wounds of varying etiologies, the most common wounds seen in this patient population are pressure-related injuries. However, there is a shortage of both wound and palliative specialized clinicians. Telehealth and the use of other technology can be a way to address this shortage. This will grant access to a broader number of patients to ensure appropriate wound care plans are in place to meet the goals of care. Although wound healing may not always be possible in this patient population, having access to specialized wound and palliative experts can improve the quality of life for patients and their caregivers.

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Current thinking on caring for patients with a wound: a practical approach

Affiliation.

• 1 Senior Lecturer, Adult Nursing, Faculty of Health and Life Science, Northumbria University, Newcastle-upon-Tyne.
• PMID: 30907641
• DOI: 10.12968/bjon.2019.28.5.290

Wound care is increasingly nurse led. This article describes the types and causes of wounds, the six domains needed for systematic wound assessment and the principles nurses can apply to ensure evidence-based wound care. The author argues for the importance of a patient-focused approach in the care of people with chronic and acute wounds. It highlights, when specialist referral may be needed and presents a case study explaining the difficulties of managing a patient with a wound at the end of life. Nurses care for people with wounds in a broad range of clinical settings and it is a real challenge to provide optimum patient outcome (wound healing) and a positive patient experience.

Keywords: Evidence-based practice; Nurse-led care; Wound care.

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• Wound and skin care for the PICU. Garvin G. Garvin G. Crit Care Nurs Q. 1997 May;20(1):62-71. doi: 10.1097/00002727-199705000-00007. Crit Care Nurs Q. 1997. PMID: 9165778 Review.
• Position statement about the role and scope of practice for wound care providers. Wound Treatment Associate Task Force. Wound Treatment Associate Task Force. J Wound Ostomy Continence Nurs. 2012 Mar-Apr;39(2 Suppl):S2-4. doi: 10.1097/WON.0b013e3182478e2f. J Wound Ostomy Continence Nurs. 2012. PMID: 22415167 Review. No abstract available.
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