Back when I was a home health nurse I loved the challenge of caring for wounds. Once I helped a Korean War veteran heal an open sore on his ankle bone he said had been there since he was frost-bitten in 1954! Another challenging wound was a man with a pressure ulcer (bedsore) whose white knobby tailbone could be clearly seen after I removed the dressing.
Remember Christopher Reeve who portrayed Superman until his neck was broken in a horse riding accident? He died because of a bed sore. The cause of death was an adverse reaction to an antibiotic he was taking for sepsis caused by his pressure ulcer. This can simplistically be thought of as a blood infection. However, sepsis occurs when chemicals released into the bloodstream to fight an infection trigger inflammatory responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail.
Although I love wounds, caring for open sores, whether caused by surgery, accident or sensation loss, is a major stressor for families and most (normal) people. Good wound care is a vital part of post-surgical recovery as well as keeping healthy and even alive. Proper wound care is necessary to prevent infection and to promote healing.
What Causes Wounds?
Wounds occur when the skin is damaged because of injury. This may be the result of mechanical, chemical, electrical, thermal, or even nuclear sources.
Skin is damaged in different ways depending upon the mechanism of injury. In all cases, inflammation (redness) is one of the first signs of injury.
Wounds are classified into types:
Superficial wounds (on the top surface layer of skin) are caused by friction rubbing against a rough surface, even something seemingly smooth like a bed sheet. They are known as abrasions or skin tears.
Additionally, many seniors take blood thinners like Coumadin® and/or low dose aspirin with resulting “bruises” where blood vessels leak into the tissue just under the skin. These obviously need protection from opening up and require prompt attention when they do.
Deep wounds, such as those following surgery, go through the skin into the underlying tissue, like muscle and fat layers.
Puncture wounds, usually caused by a sharp object entering the skin, could be as minor as a needlestick to give an injection or draw blood, or deep as a stab wound from a knife or similar sharp object.
Bites, whether human or animal, are classified as superficial or puncture wounds, depending on depth and size.
Pressure ulcers (bed sores) develop due to lack of blood supply to the skin. This is the result of chronic pressure on an area, especially over bones. This tissue compression causes a loss of blood supply to the area which increases skin breakdown. First inflammation and then sores develop when a person who is bedridden, sits for long hours in a wheelchair or has a cast pressing on the skin does not remove pressure from the area. Pressure ulcer prevention guidelines specify moving every 20 minutes to relieve compression.
Hospitals Discharge Patients ASAP
Hospitals are under tremendous insurance pressure to discharge patients as soon as possible after surgery. It’s a very confusing time for family caregivers with a discharge planner, a social worker and maybe even a wound care nurse all giving directions on the day of discharge. No wonder the many details involved in wound care are often forgotten or misremembered!
In most cases, if the wound is not considered complex, teaching is done at the time of discharge. A home health nurse will usually be assigned if the wound is complicated, such as performing wet-to-dry dressings several times each day. However, while a home care nurse keeps the patient as their primary concern, they are required to teach a family member–or a paid caregiver–how to change the dressing. Private insurance and Medicare/Medicaid will not pay for a nurse to stay in the home beyond a specified number of days after discharge.
In addition to surgical wounds, several other populations almost routinely (unfortunately) develop open sores that are specific to who they are. People who are unable to move in bed or in a chair easily often develop bed sores, also known as pressure ulcers. (Waaay back when I was just a nursing assistant, they were also known as decubitus ulcers.)
Diabetics and other people with neuropathy can develop open sores in the areas with poor sensation, like feet and lower legs, due to not feeling an offending pebble in a shoe or a bump on the shin. Preventing more open sores is a vital part of home wound care.
Proper Wound Care Procedure
- If there is any pain or discomfort with dressing changes give the patient (I’m using patient as a stand-in for the wordier but politically correct terminology of “person with a wound”) pain medication about half an hour before starting. Medications can range all the way from acetaminophen (Tylenol®) to morphine. The nurse will be able to help you decide how much pain medication to give. If the wound is particularly worrisome for the patient, ask them to practice deep breathing relaxation exercises as you do the dressing change.
- Gather all the equipment you will need. This includes the tape and dressings needed, gauze squares, saline, ointments, wound packing material, clean or sterile gloves, and any other item(s) as instructed by the nurse. Lay the materials on a clean surface in the order they will be used. Do not put dressing materials on the bed. This area is considered “dirty” from a wound care point of view–even if the sheets were just changed.
- WASH YOUR HANDS. Even when wearing gloves, it’s still important to cleanse your hands before and after touching a wound. Bacteria easily travel between your hands and the wound. You can use soap and water or an alcohol-based hand sanitizer. Scrubbing hands to the tune of the Alphabet Song (♪A, B, C, D, E, F, G♫) ensures you spend enough time to do it correctly.
- Follow the wound care written instructions given at the time of discharge.
- Additionally, remove the old dressing only after you have all supplies ready to go and the patient is medicated for pain or discomfort. Wounds need a warm and moist environment to heal. Healing is postponed if the wound is left open to the air for even a minute longer than necessary.
- Slowly lift the corners or edges of the dressing or tape. If it sticks to the skin, dab the edges with an adhesive remover, a moistened gauze pad, or a moistened paper towel.
- Hold down the skin surrounding the bandaged area. Gently and slowly remove the tape or dressing. Lift the tape across the skin rather pulling away from the skin.
- Lift the edges of the dressing toward the center of the wound, then gently lift it from the wound. If the dressing sticks to the wound, soak it with saline solution to help loosen it.
- Carefully place the old dressing into a plastic trash bag (or grocery bag) and tie it closed. Put that bag into a second plastic bag and throw it away. You can put all the packaging from the new dressing in the bag, too.
- Remove the gloves and wash your hands again.
Challenges With Chronic Wounds
Any wound that doesn’t heal easily and remains open for weeks after most similar wounds heal is considered chronic. These are among the most difficult to successfully treat. Chronic wounds can occur when:
- surgical wounds reopen or don’t heal completely
- when the skin breaks down because there is too much pressure over a bony area, called a pressure ulcer or bedsore
- there’s injury over a vein or artery in an area with poor circulation, called a venous or arterial ulcer
- there is a loss of circulation and sensation due to diabetes, called a diabetic ulcer
Many hospitals have specialized wound care clinics staffed by nurses, nurse practitioners, and physicians. These health care providers are certified in wound care and work solely with these types of chronic wounds and ulcers. They have access to up-to-date research and technology, such as hyperbaric oxygen chambers and the latest wound care dressings.
Remember, don’t forget to ask questions when the nurse is instructing you! Discharge planning has become an increasingly more important part of the hospitalization. Fines are levied for hospitals who have too many readmissions. And if the wound in question doesn’t require hospitalization, STILL don’t let the nurse get away until you have ALL your questions answered and concerns met.
I’d love to know what my readers thought of this. Was it too medical? Was it helpful? What else would you like to see me write about?